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in  tfje  Citj>  otMt'm  ^orfe 

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l^eferente  Eibrarp 


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Plate  I. 


Dementia. 


General  Paralysis. 

Frontispiece. 
From  photographs  taken  by  the  author.     See  appendix  B. 


A  MANUAL 


Psychological  Medicine 

J>r.Chas,K,MUt0 

AND 

ALLIED  NERVOUS  DISEASES. 


CONTAINING     THE     DESCRIPTION,      ETIOLOGY,      DIAGNOSIS,      PATHOLOGY,     AND     TREAT- 
MENT   OF    INSANITY,  WITH    ESPECIAL  REFERENCE  TO  THE  CLINICAL   FEATURES 
OF  MENTAL  DISEASES,  AND    THE   ALLIED  NEUROSES,  AND    ITS    MEDICO- 
LEGAL  ASPECTS,  WITH    A    CAREFULLY  PREPARED    DIGEST    OF 
THE     LUNACY     LAWS     IN     THE     VARIOUS     STATES 
RELATING   TO   THE 

CARE,    CUSTODY,    AND    RESPONSIBILITY    OF    THE    INSANE. 

DESIGNED     FOR    THE     GENERAL     PRACTITIONER     OF    MEDICINE. 

By  EDWARD  C.  MANN,  M.D., 

Memder  of  the  New  York  Medico-Legal  Society,  Etc. 
WITH    PHOTO-TYPE   PLATES    AND    OTHER    ILLUSTRATIONS. 


PHILADELPHIA: 

P.    BLAKISTON,    SON    &    CO., 

IOI2    WALNUT    STREET. 
1883. 


P'ntered  according  to  Act  of  Congress,  in  the  year  1S83,  by 

P.  BLAKISTON,  SON  &  CO., 
J 11  the  Office  of  the  Librarian  of  Congress  at  Washington. 


SHERMAN   *   CO..    PRINTEHS, 
PHILADELPHIA. 


PREFACE. 


I  HAVE  endeavored  to  present  to  the  profession  the  subject  of  in- 
sanity, and  allied  nervous  diseases,  in  a  scientific,  clinical,  and  fo- 
rensic light,  and  in  so  concise  a  form  as  to  be  available  for  the 
student  and  general  practitioner.  The  many  kind  words  of  encour- 
agement which  have  attended  my  professional  labors,  researches 
and  monographs,  proceeding  as  they  have  from  friends  occupying 
high  positions  in  the  profession,  notably  the  generous  interest  and 
recognition  from  Prof.  Oliver  Wendell  Holmes,  Dr.  Pliny  Earle, 
and  others  in  this  country,  also  from  Dr.  L.  S.  Forbes  Winslow, 
London,  England,  encourage  me  to  believe  that  this  book  on  in- 
sanity and  allied  nervous  diseases,  the  outcome  of  practical  ex- 
perience in  the  field  of  psychiatry  and  neurology,  will  be  welcomed 
by  general  practitioners  and  students  of  medicine,  and,  I  trust,  may 
not  be  entirely  devoid  of  interest  to  those  in  the  same  specialty  as 
myself — neurology. 

Psychological  medicine  occupies  a  position  of  authoritative  science, 
to  the  elaboration  of  which  has  been  directed,  and  is  still  being 
directed,  the  great  ability  of  many  of  the  most  distinguished  men  in 
the  ranks  of  medicine.  Psychological  research  commands  the  respect 
of  the  enlightened  world,  because,  industriously  pursued  from  small 
beginnings  and  unsettled  propositions,  it  has  grown  to  the  propor- 
tions of  a  well-defined  and  harmonious  system  of  science.  It  has 
become  the  adjunct  of  jurisprudence  in  settling  a  class  of  difficult 
and  otherwise  inexplicable  questions  which  arise  in  the  administra- 
tion of  justice.  The  importance  of  psychology  is  evinced  by  the 
significant  fact  that  the  necessities  of  medical  education  demand  that 
it  shall  be  taught  in  the  schools.  Journals  are  especially  devoted  to 
its  investigation,  and,  aided  by  hospitals  and  enlightened  treatment, 
it  has  declared  to  the  world  that  a  large  percentage  of  persons  re- 
cently insane  have  been  restored  to  their  friends  and  society  who, 
without  such  timely  assistance,  would  have  passed  into  the  advanced 
stage  of  mental   unsoundness.     A  very  important  point  relating  to 


IV  PREFACE. 

the  prevention  of  mental  disorders  and  the  modern  nerv^ous  diseases 
is,  that  the  growth  of  mental  function  is  as  gradual  as  that  of  bodily 
power,  and  that  brain-tissue  degenerations  and  mental  diseases  may 
be  separated  by  long  intervals  of  time  from  the  too  premature  and 
intense  stimulation  of  the  brain  in  school  children  which  causes  these 
nervous  diseases.  We  meet  with  the  preponderance  of  ner\^ous  dis- 
eases in  the  refined  and  cultivated  classes,  where,  b}^  premature  and 
stimulating  processes  of  education,  there  has  been  forced  an  elabora- 
tion of  brain-structure,  hastening  the  functional  activity  of  the  brain, 
with  no  due  regard  to  the  law  of  evolutional  precedence.  Normal 
growth  and  development  will  give  us  healthy  mind,  while  a  struc- 
turally degraded  centric  nervous  system,  or  an  altered  quality  of  blood, 
and  secondary  disturbance  of  nerve-function,  will  antagonize  healthy 
mental  manifestation.  If  we  have  want  of  sleep,  a  defective  genera- 
tion of  nerve-force,  an  unstable  condition  of  the  nerve-centres,  an 
incomplete  development  of  any  part  concerned  in  mental  action,  all 
of  which  Dr.  Blandford,  of  England,  has  ably  shown  to  be  causes  of 
mental  disease,  we  cannot  expect  healthy  mental  function.  Alcohol 
and  opium  are  to-day  responsible  for  much  deterioration  of  brain. 
Dipsomania  and  the  opium  habit  being  on  the  increase  among  Ameri- 
cans, there  is  a  greatly  increased  nervousness  and  an  increasing  in- 
herited disposition  to  the  different  neuroses ;  and  the  condition  known 
as  cerebral  hyperjemia,  an  increase  in  the  quantity  of  the  blood  within 
the  capillaries  of  the  brain,  or  rather  one  form  of  it,  of  vaso-motor 
origin,  resulting  from  overwork  and  mental  strain,  is  greatly  on  the 
increase. 

In  diseases  of  the  brain  both  the  regional  diagnosis  and  the 
pathological  diagnosis  are  to-day  attracting  much  attention,  and  the 
brilliant  work  of  such  writers  as  Drs.  H.  Charlton  Bastian,  L.  S. 
Forbes  Winslow,  Bucknill  and  Tuke,  Prof.  Krafft-Ebbing,  Drs.  A. 
Voison,  Foville  and  Luys,  Clouston  and  Blandford,  Loggia,  Hitzig, 
Ferrier,  Charcot  and  Lusanne,  Brown-Sequard,  and  Hughlings  Jack- 
son, in  England,  Germany,  France,  and  Italy,  with  the  able  work  of  our 
neurologists  and  asylum  superintendents  at  home,  makes  the  writer 
only  too  conscious  of  his  own  defects  in  this  field  of  research. 

Insanity  is  not  onl}-  appearing  at  an  earlier  age  than  formed}^,  but 
there  is  also  a  decided  increase  of  insanity  disproportionate  to  the 
increase  of  population.  Educational  pressure  on  the  young,  to  the 
neglect  of  physical  exercise,  the  increasing  artificial  and  unnatural 
habits  of  living,  the  great  excitement  and  competition  in  business,  are 


•  PREFACE,  V 

all  tending  to  induce  and  multiply  nervous  diseases,  many  of  which 
must  terminate  in  mental  diseases.  As  to  men,  I  think,  modern 
nervousness  is  largely  due  to  mental  anxiety  respecting  business,  the 
abuse  of  alcohol  and  tobacco,  and  sexual  excess.  These  three  things, 
in  combination,  will  break  down  and  shatter  the  strongest  constitu- 
tion, and  induce  ataxy,  paresis,  and  insanity  in  those  who  inherit 
weak  nervous  systems  from  their  progenitors.  Regular  hours,  amuse- 
ments to  divert  the  mind  from  the  cares  of  business,  freedom  from 
alcoholic  stimulants,  nourishing  food  at  regular  hours  and  properly 
digested,  abstinence  from  tobacco  during  the  years  previous  to  puberty 
and  until  twenty  years,  and  daily  attention  to  the  bowels,  with  free 
bathing,  will  keep  most  men  in  robust  physical  and  mental  health. 
Herbert  Spencer,  in  his  "  Social  Statics"  page  413,  speaks  thus  re- 
specting the  wise  severity  of  nature's  discipline: 

"  Partly  by  weeding  out  those  of  lowest  development,  and  partly 
by  subjecting  those  who  remain  to  the  never-ceasing  discipline  of 
experience,  nature  secures  the  growth  of  a  race  who  shall  both  un- 
derstand the  conditions  of  existence,  and  be  able  to  act  up  to  them. 

And  by  multiplication  of  such  warnings  (the  warnings  of 

ignorance,  and  its  consequence,  sickness  and  pain)  there  cannot  fail 
to  be  generated  in  all  men  a  caution  corresponding  to  the  danger  to 
be  shunned.  Are  there  any  who  desire  to  facilitate  the  process? 
Let  them  dispel  error ;  and,  provided  they  do  this  in  a  legitimate  way, 
the  faster  they  do  it  the  better."  Any  work  that  we  as  physicians 
do  towards  influencing  the  public  to  study  the  laws  of  health,  to  reform 
their  habits  of  living,  to  promote  the  use  of  baths,  to  encourage  tem- 
perance, ventilation,  and  due  exercise,  and  to  further  a  knowledge 
of  the  human  organism  and  the  laws  which  regulate  it,  and  in  dif- 
fusing a  knowledge  of  all  the  means  necessary  for  the  preservation 
of  good  health,  will  produce  its  exact  equivalent  of  results  in  the 
-^prevention  of  insanity.  We  shall  thus  develop  in  the  masses  an  in- 
telligent, self-helping  character,  tending  to  robustness  of  body  and 
robustness  of  mind.  Nature  has  attached  to  ignorance  of  her  laws 
or  their  non-observance  certain  penalties,  and  she  always  punishes 
every  breach  of  these  laws.  All  measures  which  we  take  to  replace 
ignorance  by  wisdom  will  inevitably  check  the  growth  of  insanity. 

From  our  long  experience  and  repository  of  facts,  it  is  inexcusable 
if  we  cannot  obtain  some  information,  or  if  knowledge  cannot  be  in 
some  way  secured,  to  check  the  increase  of  insanity.  We,  as  physi- 
cians, must  make  it  our  concern,  charge  ourselves  with  this  specific 


VI  PREFACE. 

duty,  and  continue  it  from  year  to  year,  and,  although  each  individ- 
ual's work  may  be  small,  the  aggregate  result  will  be  immense  for 
our  fellow-men. 

While  I  have  freely  expressed  my  own  ideas  on  those  diseases 
with  which  I  am  most  conversant,  and  recommended  the  treatment 
which  in  my  hands  has  proved  the  most  successful,  I  would  earnestly 
advise  young  practitioners  to  be  guided  in  their  treatment  of  both 
mental  and  nervous  diseases  by  the  symptoms  and  individual  charac- 
teristics of  each  case,  and  not  to  adopt  any  routine  treatment,  if  they 
would  make  successful  practitioners. 

I  have  to  express  my  warmest  thanks  to  friends  for  aid  rendered 
me  in  various  ways,  but  more  especially  to  Dr.  Robt.  J.  Hess  of  Phila- 
delphia, and  to  William  J.  Mann,  Esq.,  of  the  New  York  Bar.  The 
former  has  kindly  made  a  most  careful  study  and  critical  analysis  of 
the  book,  and  has  favored  me  with  valuable  suggestions  respecting 
the  arrangement  of  my  work  of  which  I  have  taken  advantage,  and 
by  correcting  the  sheets  during  their  progress  through  the  press  has 
laid  me  under  many  obligations.  The  latter  gentleman,  my  brother, 
kindly  consented  to  prepare  the  entire  abstract  of  the  laws  relating 
to  the  care  and  protection  of  the  insane  in  every  State  of  the  Union, 
greatly  increasing  the  value  of  the  book,  especially  to  the  legal  pro- 
fession, giving  it  a  medico-legal  importance  which  otherwise  it  could 
not  have  had. 

28  West  Thirtieth  Street,  New  York,  Oct.  ist,  1883. 


CONTENTS. 


CHAPTER  I. 

PAOE 

ON    INSANITY    IN    GENERAL,    ITS    HISTORY   AND    CLASSIFICATION,       .  .37 

CHAPTER  II. 

THE    ETIOLOGY    OF    INSANITY,  AND  THE    IMPORTANCE    OF    ITS    EARLY    RECOG- 
NITION  AND    REPRESSION    IN    THE    INCIPIENT    STAGES. 

Insanity  caused  by  defect  of  nerve-force  and  an  unstable  condition  of  the  cerebral 
centres — By  incomplete  development — By  ill  health — Intemperance — Grief — 
Loss  of  friends — Mental  anxiety  and  sleeplessness — ■Blovi's  on  the  head,  etc. — 
Causes,  predisposing  and  exciting,  .........       52 

CHAPTER  III. 

PREVENTION    OF   INSANITY,      .  .  I 64 

CHAPTER  IV. 

DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY, 67 

CHAPTER  V. 

CIVIL  INCAPACITY — LEGAL  TESTS  OF  RESPONSIBILITY — HINTS  FOR 
GIVING  TESTIMONY,  EXPERT  TESTIMONY,  AND  THE  FUNCTIONS 
OF    EXPERTS    IN    INSANITY, 86 

CHAPTER  VI, 

GENERAL   PARALYSIS   OF   THE    INSANE    (DEMENTIA    PARALYTICA),     .  .       95 

CHAPTER  VII. 

IDIOCY — DEMENTIA — FOLIE   RAISONNANTE    (REASONING    MANIA). 
Moral  and  affective  insanity — Impulsive  insanity,  • .  ......     105 

CHAPTER  VIII. 

MENTAL  RESPONSIBILITY  AND  THE  DIAGNOSIS  OF  INSANITY  IN  CRIM- 
INAL  CASES, 119 


Vlll  CONTEXTS. 


CHAPTER  IX. 

PAGE 

THE    HISTOLOGY    AND    FUNCTIONS    OF    THE    BRAIN,      .  .  .  .  •     I3I 

CHAPTER  X. 

THE    PATHOLOGY    AND    MORBID    HISTOLOGY    OF    ACUTE    AND    CHRONIC 

INSANITY. 

The  membranes— Epithelium — Nerve-cells— Nerve-fibres— Special  morbid  condi- 
tions of  gray  matter — The  neuroglia — Sclerosis— Bloodvessels  and  sympathetic 
nerve-cells — Examination  of  blood  and  urine  from  the  insane,         .  .  .      139 

CHAPTER   XL 


CASES     ILLUSTRATING     PATHOLOGY     AND     MORBID     HISTOLOGY     OF     IN- 
SANITY,          


153 


CHAPTER   Xn. 

TREATMENT    OF    INSANITY. 

General  observations — The  brain  to  be  looked  at  as  a  whole,  and  medicines  must 
be  calculated  to  act  upon  it  through  the  general  system — Insanity  a  curable 
disease  if  promptly  treated  at  the  outset  of  the  disease — If  neglected,  soon  tends 
to  induce  organic  degeneration,  which  renders  it  incurable — Moral  treatment 
— Choice  of  asylum — Proper  attendants— Food — Work — Amusements — Me- 
dicinal treatment — Question  of  non-restraint — Home  treatment  of  the  quiet  in- 
sane as  private  patients  in  private  dwellings — Dr.  Maudsley's  opinion — Lunacy 
Commission — Opium— Hydrate  of  chloral — Hyoscyamia — Digitalis — Ergot — 
Bromide  of  sodium — Bromide  of  lithium — Bromide  of  zinc — Phosphorus^ 
Strychnia — Iron — Calomel^Tincture  cannabis  indica  and  sodium  bromide — 
Prolonged  warm  baths  with  cold  to  the  head — The  galvanic  current  of  elec- 
tricity in  congestive  states  and  as  a  tonic  to  the  central  nervous  system— Opium 
effectually  antagonizes  suicidal  melancholia  when  used  in  connection  wtth  pro- 
longed warm  baths— Tincture  black  hellebore  and  apiol  as  emmenagogues — 
Combinations  of  sedatives  in  insanity  generally  the  best  practice — Monobro- 
mide  of  camphor — Fothergill's  solution  of  hydrobromic  acid — Chloro-phos- 
phide  of  arsenic  (Routh's  formula) — Conium — Cases  illustrating  the  treatment 
of  insanity— Views  of  Dr.  Pliny  Earle,  Dr.  John  P.  Gray,  Dr.  I'homas  S.  Kirk- 
bride,  Dr.  Henry  P.  Stearns,  Dr.  Nichols,  and  others, 157 

CHAPTER  Xni. 

INSANITY    IN    THE    MIDDLE    STATES. 

Insanity  increasing  disproportionately  to  the  increase  of  population —New  York: 
Utica  Asylum — Hudson  River  State  Hospital  at  Poughkeepsie— The  State 
Homceopathic  Asylum  for  Insane  at  Middletown— Buffalo  State  Asylum  for 
Insane— New  York  State  asylums  for  die  chronic  insane:  The  Willard  Asylum 
at  Ovid  and  the  Binghamton   State  Asylum  for  the  Chronic  Insane— Kings 


CONTENTS. 

County  Lunatic  Asylum  at  Flatbush-New  York  County  asylums  on  Ward', 
and  Blackwell's  Lslands-The  New  Jersey  State  Lunatic  Asylum  at  Trento-" 
N.  J._The  new  asylum  at  Morristown,  N.  J._The  four  Pennsylvania  State 
hospitals— Insane  m  Delaware,  in  almshouses,  etc., 

CHAPTER  XIV. 

PROVISION    FOR    THE    CHRONIC    INSANE. 
I^arge,  expensive  institutions  a  mistake. 


IX 


PAGE 


266 


271 


CHAPTER  XV. 

LUNACY    IN    ENGLAND    AND    SCOTLAND. 
The  views  of  the  late  Dr.  Forbes  Winslow  on  the  treatment  of  insanity,  .         .     275 

CHAPTER  XVI. 

THE    NECESSITY    FOR   A   NEW   METHOD    OF    INTRODUCING   EXPERT   TESTIMONY 
IN    CRIMINAL    TRIALS    WHERE    INSANITY    IS    ALLEGED    AS    A    DEFENCE. 

States  should  be  districted  and  a  physician  in  lunacy  appointed  for  each  district  by 
the  Governor-This  board  of  psychological  experts  should  constitute  a  State 
lunacy  commission  and  examine  all  cases  before  trial— Dr  D  Hack  Tuke's 
opinion-Laws  of  Austria-Laws  of  France-Law  of  insanity  should  be  more 
conformable  than  it  is  with  medical  science-The  immense  medico-legal  im- 
portance of  the  recognition  of  the  mental  condition  that  is  the  precursor  of 
decided  insanity:  Depression,  unwonted  excitability,  disregard  of  the  minor 
proprieties  of  life,  change  of  affections,  sleeplessness,  change  of  character,  loss 
of  self-control,  and,  finally,  the  downfall  of  the  integrity  of  the  intellect,         .     296 

CHAPTER  XVII. 

CODIFICATION    OF    THE    COMMON    LAW    AS    TO    INSANITY. 
Lord  Justice  Bramwell's  opinion-Lord  Justice  Blackburn's  opinion-Opinion  of 
tlie   Lord  Chief  Justice  of  England  and  of  Lord  Moncrief,  the   Lord  Justice 
Clerk  of  Scotland-Of  the  late  Dr.  Ray-Sir  Fitzjames  Stephen's  attempt  to 
codify  the  common  law  of  England  on  insanity-The  physiciai.  studies  the 
whole  history  of  his  patient  and  his  ancestiy  and  searches  for   the  causes  of 
any  bodily  and  mental  changes  that  he  finds,  and  thus  arrives  at  the  true  pa- 
thology of  the  disease ;  while  the  lawyer  and  jurist  are  mainly  interested  in  the 
existence  of  mental  disease,  its  degree,  and  its  influence  on  conduct-Why  the 
apparent  unwillingness  to  recognize  disease  in  the  homicidal  act  when  the 
physician  and  jurist  alike  are  willing  to  recognize  disease  m  the  suicidal  act? 
-We  must  look  at  these  questions  by  the  aid  of  the  light  of  modern  pathology 
as  the  Lord  Chief  Justice  of  England  has  done  already-People  born  with  a 
predisposition  to  insanity  manifest  slight  symptoms  for  years,  but  not  sufficient 
to  induce  their  friends  to  treat  them  as  insane-When  an  overt  act  is  com- 
mitted, who  can  question  the  value  of  a  careful  examination  of  the  past  life 
and  acts  of  the  accused  ?-His  life  has  exhibited  the  natural  history  of  insanity 


CONTENTS. 


— The  psychological  expert  can  point  out  clearly  to  the  jurist  the  unmistakable 
evidences  of  mental  disease,  which  the  latter,  necessarily,  alone  and  unaided, 
could  not  discover — There  should  be  no  rule  of  law  that  conflicts  with  the 
elementary  truths  of  insanity,  on  which  only  such  rules  should  be  founded,     .     302 


PART   II. 

INTRODUCTORY  CHAPTER  ON  MODERN  NERVOUS  DISEASES. 

Neurotic  affections  increasing  and  multiplying — We  have,  as  Americans,  a  morbid 
nervousness  which  is  a  new  state  of  the  system — Our  increased  nervousness 
evinced  by  the  connection  with,  and  influence  of  the  ner\'0us  system  on  other 
diseases  not  properly  nervous — Increased  consumption  of  neurotic  remedies 
in  this  country — The  neurotic  circle  in  society  constantly  increasing,  out  of 
proportion  to  the  increase  of  population,  equally  with  the  distinctly  insane 
circle  of  society,  causes  increased  complexity  of  the  central  nervous  system 
and  of  life — -Probable  elaboration  in  structure  of  the  brain  due  to  the  demands 
of  a  modern  civilization  upon  it — Modern  system  of  education  influential  in 
the  production  of  nervous  and  mental  disorders  of  a  grave  type — Brain  exhaus- 
tion and  organic  disease  thus  induced — The  exhaustive  effects  of  excessive 
and  ill-directed  brain  work  in  our  modem  schools — The  whole  future  com- 
plexion of  mental  Ufe  in  great  part  determined  by  the  impressions  made  on  the 
sensory  centres  of  the  brain  when  they  are  undergoing  development — The  dif- 
ficulty of  making  even  cultured  people  understand  that  brain-tissue  degenera- 
tions and  mental  diseases  may  be  separated  by  long  intervals  of  time  from  the 
too  premature  and  intense  stimulation  of  the  brain  which  causes  these  nerve 
and  brain  diseases — Brain  disease  much  increased  in  our  period  of  civilization 
as  compared  with  a  former  and  more  primitive  period — By  cautious  stimulation 
of  the  brain  we  bring  it  to  its  highest  development;  by  undue  haste  we  ruin 
its  functional  activity  forever — Wakefulness  and  restlessness  to  be  met  by 
promptly  leaving  one's  business  and  taking  complete  physical  and  mental  rest 
— Mental  anxiety,  by  producing  sleeplessness  and  unrefreshing  sleep,  quickly 
disturbs  the  normal  balance  of  the  ner^-ous  system  and  deranges  its  functions — 
Syphilitic  nervous  disease  and  its  diagnosis,    .         .         .         .         .         .         •     311 

CHAPTER  XVIII. 

GENERAL  CONSIDERATIONS  ON  THE  DEVELOPMENT  OF  THE  NERVOUS  SYSTEM 
BY  EVOLUTION,  AND  THE  CONDITION  OF  THE  BRAIN  IN  HEALTH  AND 
DISEASE,  AND  GENERAL  REMARKS  ON  THE  REGIONAL  DIAGNOSIS  OF 
DISEASES   OF   THE    SPINAL   CORD    AND    BRAIN. 

The  simplest  nervous  apparatus,  one  ganglion  situated  in  the  neighborhood  of  the 
mouth,  in  the  mantle,  and  giving  off  cords  which  proceed  to  the  sense  and  di- 
gestive organs  of  the  ascidian  mollusc — The  echinoidea,  the  annulosa,  having 
a  chain  of  ganglia  running  the  whole  length  of  the  body,  united  by  nervous 
cords — The   insecta,  having  two  cords  passing  backwards  from  the   cephalic 


CONTENTS.  XI 

PAGE 

above  the  ventral  ganglia,  and  giving  off  branches  to  them  and  to  the  body 
walls — This  the  most  rudimentary  form  of  the  cerebro-spinal  system — The 
vertebrata — The  lancelet,  the  vertebrate  with  the  simplest  nervous  system  — 
The  renal  axis  of  this  animal,  a  delicate  tract  of  nucleated  cells,  surrounded 
by  a  covering  of  pia  mater,  and  fifty  or  sixty  pairs  of  nerves  given  off  laterally — 
Lamp7-eys  possess  a  higher  organization,  as  they  have  a  cartilaginous  cranium, 
with  a  spinal  cord  extending  anteriorly — The  cod  and  shark  higher  yet;  the 
posterior  fissure  widens,  and  the  halves  of  the  cord  expand — Two  lateral  , 
columns  project  into  the  ventricle  from  the  conjoined  restiform  and  posterior 
pyramidal  tracts — Cerebellum  and  crura  cerebelli  added  next  in  process  of  evo- 
lution, etc. — Crocodile — Bird— Dog — The  cerebra  AtyrtAo^  pari  passu  with  the 
animal's  degree  of  intelligence — Multiplication  of  ganglia  always  accompanied 
by  a  corresponding  differentiation  of  ganglionic  functions,  some  being  devoted 
to  sight,  others  to  controlling  muscular  tissue,  etc.^The  nervous  system  always 
adapted  to  the  general  structure  of  the  animal — The  pre-oesophageal  ganglion 
of  the  annulosa  the  direct  homologue  of  the  vertebrate  brain — In  the  highest 
vertebrates  reflex  movements  take  place  through  the  brain,  spinal  cord,  and 
sympathetic  system — These  govern  the  visceral  functions,  and  are  connected 
with  the  voluntary  actions  of  life — In  the  evolution  of  the  nervous  system  the 
brain  or  cephalic  ganglion  is  gradually  increased  in  motor  and  sensory  power, 
and  the  non-cephalic  ganglion  relatively  lessened,  the  nervous  apparatus  grad- 
ually gaining  in  complexity,  until  man  is  reached,  where  we  find  the  nervous 
system  comprising  the  cerebrum  and  cerebellum,  with  the  various  ganglia  and 
commissures  which  belong  to  these  bodies,  the  medulla  oblongata,  the  spinal 
cord,  the  sympathetic  ganglia,  and  the  nerves  which,  springing  from  these 
several  sources,  are  distributed  throughout  the  organism,  etc. — -General consid- 
erations on  the  diagnosis,  pathology,  and  treatmejit  of  nervous  diseases — Gen- 
erally, a  perfect  accord  between  the  cortkfal  lesion  in  the  brain  and  the  periph- 
eral and  functional  lesion,  and  we  find  the  same  parallelism  between  the-  in- 
tensity of  the  lesion  of  movements  and  the  gravity  of  the  lesion  in  the  cortical 
motor  zone — From  the  region  of  the  body  where  the  convulsive  movements 
commence  in  nervous  disease,  we  may,  with  certainty,  diagnosticate  the  cortical 
brain-centre  primitively  and  principally  affected,  which  will  be  that  correspond- 
ing to  the  group  of  muscles  earliest  brought  into  action — Rules  for  localizing 
chronic  lesions  of  the  nervous  centres — The  appearance  of  synchronous  and 
symmetrical  paraplegia — Paraplegia  of  the  legs — Cerebral  paraplegia — Ta- 
betic symptoms — Progressive  muscular  atrophy— Hemiplegia  with  opposite 
hemiansesthesia — Bilateral  tabetic  neuralgia  of  the  legs  and  arms  in  central 
neuroses  — Progressive  paralysis  of  cerebral  nerves — Paraplegia  of  the  tongue 
(alalia) — Hemiplegia,  with  opposite  facial  or  oculo-motorius  paralysis — Hemi- 
plegia, with  hemianjesthesia  of  the  same  side — -Hemiplegia,  with  incomplete 
facial  paralysis  (the  upper  branch  rero^aining  free) — Hemiplegia,  with  convul- 
sions— Diseases  of  the  meninges — Static  vertigo — Contractions  of  central  origin 
— Tremors — Influence  of  sensorial  irritation  upon  phenomena  due  to  motor 
irritation — Phenomena  of  motor  irritation  from  centric  causes — -The  diagnosis 
of  diseases  of  and  injuries  to  the  spinal  cord — Paralysis  of  voluntary  move- 
ments, of  the  muscular  sense,  of  the  vaso-motor  nerves,  hypersesthesia,  ocular 
and  facial  s3'mptoms  on  both  sides  of  the  body,  ansesthesia  in  one  lateral  half 
of  the  body — We  can  make  an  exact  diagnosis  as  to  the  seat  of  the  lesion  : 


Xll  CONTEXTS. 

PAGE 

Lesion  in  the  pons  varolii,  lesions  in  the  crus  cerebri,  lesions  in  the  optic  thal- 
,  amiis,  lesion  in  corpus  striatum,  lateral  ventricles,  lesions  in  the  anterior, 
middle,  aftd  posterior  parts  of  the  cerebral  hemispheres — Symptoms  of  critical 
affections  of  the  brain— Lesions  of  the  cerebellum — Pathological  diagnosis — 
Sudden  haemorrhages — Prognosis  in  cerebral  haemorrhages — To  avert  threat- 
ened cerebral  hsemorrhages,    ..........     319 

CHAPTER  XIX. 

DIPSOMANIA. 

Dipsomania,  a  true  periodical  insanity,  a  form  of  physical  disease — Differs  from  the 
physiological  state  in  which  the  individual  merely  chooses  to  indulge  in  liquor 
to  excess — The  great  diagnostic  point  of  the  disease,  the  irresistible  impulse, 
by  which  the  patient  is  impelled  to  gratify  his  morbid  propensity,  being,  during 
the  paroxysm,  blind  to  all  the  higher  emotions,  and  pursuing  a  course  against 
which  reason  and  conscience  alike  rebel — These  paroxysms  preceded  by  con- 
siderable disturbance  of  the  nervous  system,  etc. — Treatment,  judicious  re- 
straint— A  permanent  recovery  depends  on  allowing  sufficient  time  for  restora- 
tion of  the  nerve-power,  mental  tone,  and  physical  vigor,  and  for  complete  re- 
cuperation of  the  will-power,  etc. — Nervous  exhaustion  and  premature  mental 
decay  from  dipsomania,  and  its  treatment,  etc.,         ......     354 

CHAPTER   XX. 

HYSTERIA. 

Causes,  symptoms,  pathology,  diagnosis , prognosis ,  a?id treatment — Principal  charac- 
teristics of  hysteria  consist  in  an  exaggeration  of  involuntary  motility,  and  a 
diminution  of  the  power  of  the  will — Voluntaiy  movements  not  properly  exe- 
cuted, while  the  reflex  sensational  and  emotional  movements  are  abnormally 
active — The  will  determined  by  the  ideas,  feelings,  and  fancies — The  patient 
cares  nothing  for  her  duties,  and  takes  pleasure  in  exaggerating  all  her  slight 
discomforts  and  annoyances,  and  by  her  suspicious,  exacting,  and  unreasonable 
behavior  makes  life  generally  uncomfortable  to  her  friends — ^Hysterical  patients 
must  be  unconsciously  guided  away  from  self,  and  into  new  grooves  of  thought, 
feeling,  and  action— Electricity,  exercise,  tonics,  etc.  and  removal  from  home 
— The  psychical  treatment,  away  from  home,  of  primary  importance,        .  .     376 

CHAPTER   XXL 

EPILEPSY. 
Definition — Causes — Symptoms — Pathology — Diagnosis — Prognosis — Treatment,  .     417 

CHAPTER  XXH. 

HYSTERO-  EPILEPSY. 

Symptoms — Pathology — Diagnosis — Prognosis — Treatment — History  of  a  very  un- 
usual case  of  hystero-epiiepsy,  with  removal  of  both  ovaries,  ....     442 


CONTEXTS.  XI 11 

CHAPTER  XXIII. 

CHOREA. 

PAGE 

Symptoms — Causes — Pathology — Diagnosis- —  Prognosis  and  Treatment- — Chorea 
occurs  at  a  time  when  the  nutrition  of  the  brain  is  passing  through  a  state  of 
transition,  from  that  of  infancy  or  early  childhood  to  that  of  the  adult  period — 
The  lesion  one  of  mal- nutrition  and  irritation — Treatment  must  be  tonic  and 
bracing  to  the  nervous  system,  cold  sponge  baths,  chalybeates,  quinine,  and 
other  metallic  tonics — A  tendency  in  the  worst  cases  to  run  into  one  or  other  of 
the  inflammatory  diseases  of  the  brain  and  spinal  cord — General  unilateral  ten- 
dency of  chorea — Symptoms  connected  with  a  morbid  irritability  of  the  cere- 
bral convolution,  ganglion  at  the  base  of  the  brain,  the  pons,  the  medulla  and 
the  spinal  cord — The  disease  depends  upon  hypersemia  and  mo'bid  irritability 
of  the  nervous  centres — Hereditary  chorea,     .......     449  ■ 

CHAPTER  XXIV. 

VERTIGO. 
Definition — Causes — Varieties — Prognosis — Treatment,  .....     462 

CHAPTER  XXV. 

STATES    OF    UNCONSCIOUSNESS. 
Somnambulism — Catalepsy — Trance  and  Trance  Coma,  .....     466 

CHAPTER  XXVI. 

CEREBRAL    AND    SPINAL    ANEMIA. 

Frequence  among  American  women — A  disease  of  capillary  contraction  and  blood- 
lessness — Symptoms  of  cerebral  irritation  present — May  be  great  disturbances 
of  sensibility — If  not  checked,  lapses  into  melancholia  and  dementia,  ending 
in  psychical  torpidity  and  intellectual  decay— The  state  of  ansemia,  if  carried 
beyond  a  certain  point,  will  destroy  functional  activity  and  the  activity  of  the 
brain — Treatment — Psychical  and  medicinal — Electricity,  etc.,  must  improve 
quantity  and  quality  of  blood  circulating  in  the  brain  and  spinal  cord,     .  .     490 

CHAPTER  XXVII. 

INFLAMMATORY    DISEASES    OF    THE    BRAIN    AND    ITS    MEMBRANES. 

Periphery  of  brain  very  sensitive,  and  injuries  of  this  portion  attended  with  very 
serious  results — Inflammation  of  membranes  followed  by  formation  of  pus  or 
effusion  of  serum  or  of  lymph — Idiopathic  encephalitis  very  rare — All  external 
injuries  to  head  of  great  importance  owing  to  anatomical  relationship  between 
the  pericranium  and  the  dura  mater — Stage  of  invasion  and  stage  of  effusion  in 
meningitis — Rigors,  pain  in  head,  intolerance  of  light  and  noise,  and  irritability 
of  temper — Symptoms — Differential  diagnosis  at  onset  of  typhoid  fever  and 
delirium  tremens,    .  .  .  ,  .  .  .  .  .  .  .  .496 


XIV  CONTENTS. 


CHAPTER  XXVIII. 

NEURALGIA. 

PAGE 

General  tonsiderations,  varieties  and  treatment — Pathology  of  neuralgia  consists  in 
the  functional  impairment  of  the  sensor}'  nerve-cells  of  the  central  sensory 
tract  of  the  nervous  system  which  is  the  seat  of  ner\'ous  sensibility — In  neu- 
ralgia of  extremities  we  should  search  for  trouble  or  injur}-  to  the  trunk  of  the 
nerve  whose  sentient  extremities  are  affected^Exit  of  the  cranial  nerves,  neu- 
ritis and  neuralgia — Visceral  neuralgias — Hypodermics  of  atropia — Neuralgia 
sometimes  dependent  upon  peripheral  vaso-motor  disturbance,  but  the  nei-ve- 
ceiitres  generally  the  seat  of  the  disease — Neurasthenia  or  ner\-ous  exhaustion 
the  most  important  predisposing  cause— Tendency  of  neurasthenia  toward  in- 
cipient insanity — Motor  phenomena,  loss  of  muscular  power  and  endurance — 
The  secreto-motor  part  of  the  nervous  apparatus  disturbed — Hemorrhoids, 
impacted  faeces,  and  affections  of  the  urinar}'  organs  causes  of  visceral  neural- 
gias— Diseased  ovaries — Exostoses  in  frontal  sinuses  or  in  the  ethmoidal  or 
sphenoidal  bones,  or  on  the  roots  of  the  teeth — Treatment — Professor  Erb,  of 
Heidelberg,  on  electricity  as  a  therapeutic  agent  in  neuralgia — Static  electricity 
and  continuous  galvanic  current,     .........     501 

CHAPTER  XXIX. 

LOCOMOTOR    ATAXLA.  (POSTERIOR    SPINAL    SCLEROSIS)  CEREBRAL    HVPER.EMIA, 
CEREBRAL    SOFTENING,    AND    CEREBRAL    SCLEROSIS. 

Description— Symptoms — Clinical  history  and  treatment — Premonitor}'  symptoms 
of  posterior  spinal  sclerosis — Paroxysms  of  pain  of  a  neuralgic  character,  wan- 
dering and  of  a  stabbing,  boring  nature,  generally  in  the  feet  and  legs — Dimi- 
nution of  the  patellar  tendon,  vesical,  rectal,  and  pupillary  reflexes,  and 
plantar  anaesthesia — Crises  gastn'ques  of  Charcot — Osteo-arthritic  changes — 
Treatment,      .  .  .  .  .  .  .  .  .  .  .  .  .518 

CHAPTER  XXX. 

ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  Faradic  current — The  constant  or  galvanic  current  and  static  electricity — 
When  indicated  and  how  to  be  used — Dr.  J.  Russell  Reynolds,  Dr.  A.  D.  Rock- 
well, Dr.  Wilks,  Dr.  Poore,  Dr.  Buzzard,  and  Dr.  Althaus,  on  clinical  uses  of 
electricity,       .............     546 

CHAPTER  XXXI. 

SPINAL   CONCUSSION. 

Viewed  in  a  scientific,  clinical,  and  forensic  light — Eflects  as  a  rule  remote  rather 
than  immediate — The  mind  affected  quite  as  seriously  as  the  body — Medico- 
legal relation  and  significance — The  spinal  cord  may  be  functionally  disturbed 
and  even  organically  diseased  from  any  and  all  such  spinal  shocks  and  inju- 
ries—Local and  constitutional  immediate  and  remote  effects  from  these  inju- 


CONTENTS.  XV 


ries — Primary  effects  due  to  molecular  changes — Secondary  effects  of  an  in- 
flammatory nature — The  length  of  time  that  may  elapse  between  the  injury 
and  the  development  of  symptoms — Meningitis — Myelitis  and  meningo-myelitis 
— Necessarily  fatal  injuries  to  the  spine  from  indirect  vialence — Variation  in  pa- 
ralysis— Slowly  developed  spinal  meningitis  from  spinal  injury  in  railway  col- 
lisions terminating  in  death  eventually — Paraplegia  and  slow  recovery — Inju- 
ries to  the  back  without  apparent  mechanical  lesion — Slight  injuries  followed 
by  fatal  results — Sensory  disturbances — Nervous  shock,  no  immediate  effects 
and  chronic  meningitis  with  imperfect  recovery — General  shocks  the  result  of 
railway  collision,  etc. — Treatment,  ........     608 

CHAPTER  XXXII. 

THE    PSYCHOLOGY    OF    CRIME. 

The  degree  of  responsibility  which  attaches  to  the  class  who  are  periodically  or  con- 
stantly impelled  to  commit  crime — A  pathological  state  of  the  brain  connected 
with  a  peculiar  skull  development  (shortening  of  the  occiput,  anterior  vertex 
steepness,  ^'^  scheitelsteilheit^''  asymmetry,  and  flattening  of  occiput) — Professor 
Moriz.  Benedikt's  researches — The  varieties  of  skull  development  which  play 
a  part  in  the  natural  history  of  crime — An  anthropological  change  lies  at  the 
foundation  of  criminal  propensities — A  deficient  organization  lies  at  the  base 
of  criminal  natures  and  is  the  cause  of  the  abnormal  moral  constitution — Exam- 
ination of  four  criminal  brains  by  Professor  Benedikt — Want  of  prominence  of 
the  extei-nal  occipital  protuberance  and  flatness  of  occiput — -Vertex  steepness 
(rising  up  from  before  backwards),  present  in  55  per  cent,  of  habitual  thieves' 
skulls — (The  highest  point  of  the  crown  generally  stands  a  little  higher,  one 
and  a  half  centimetre,  than  the  boundary  line  between  the  part  of  the  fore- 
head covered  with  hair  and  that  which  is  uncovered — The  proportion  is  altered 
in  habitual  thieves,  and  there  are  differences  amounting  to  seven  centimetres— 
The  frontal  diameter  at  the  top  of  the  crown  is  broad,  and  broader  than  that 
of  the  forehead ;  and,  lastly,  the  highest  protuberance  of  the  two  parietal 
bones  lies  commonly  in  such  an  oblique  horizontal  line  that  one  end  of  it  lies 
before  and  the  other  behind  the  ear) — Murder  often  the  result  of  ethical  weak- 
ness or  imbecility  because  the  materials  for  the  formation  of  the  higher  feelings 
are  absent — Construction  of  the  skull  proportionate  to  the  whole  anthropologi- 
cal organization  in  animals  and  man — The  ethic  constitution  or  development 
is  wanting  which  is  necessary  to  the  foundation  of  the  feeling  of  what  is  right — 
There  is  a  predisposition  to  crime  as  to  insanity — The  brain  comes  into  the 
world  with  the  same  imperfections  and  deficiencies,  the  same  irresistible  ten- 
dencies to  disease  or  perversity  of  action,  which  have  long  been  observed  with 
regard  to  other  organs  — Imperfection,  deficiency  or  obliquity  are  the  result  of 
organic  influences,  and  abnormal  mental  and  moral  phenomena  rjsult — The 
necessity  for  moral  pathology  to  be  raised  to  a  science — An  irresistible  impulse 
to  do  or  say  a  thing  abhorrent  to  one's  own  idea  of  fitness  or  morals,  significant 
of  the  inheritance  of  a  tendency  to  mental  disease — The  mental  responsibility 
of  those  with  the  peculiar  cerebral  condition  which  is  produced  by  tendencies 
to  disease  or  ancestral  vices — The  laws  of  hereditary  transmission  imperfectly 
understood — The    conditions   of    mind    implying    abnormal    imperfection    of 


XVI  CONTENTS. 


the  brain  very  imperfectly  studied  and  understood — Science  claims  recognition 
of  the  fact  that  the  course  of  thought,  the  sense  of  moral  distinction  and  con- 
duct are  greatjy  affected  by  congenital  imperfections  of  the  brain — Responsi- 
bility to  depend  on  this  fact — A  family  saturated  with  insanity  will  generally 
exhibit  some  criminal  moral  obliquity,  frequently  witnessed  in  abnormal 
mental  states — Legal  responsibility  only  to  be  ascertained  by  a  thorough  inves- 
tigation of  the  circumstances  of  each  individual  case — A  good  physical  edu- 
cation and  sound  mental  discipline  necessary  to  antagonize  diseased  tenden- 
cies, etc.,        .         .         .         .         .         .         .         .         .         .         .         .         .617 


APPENDIX. 

A. 

An  Abstract  of  the  Laws  Relating  to  the  Care  and  Custody  of  the   Insane  in  the 

various  States  of  the  Union.     By  William  J.  Mann,  Esq.,  of  the  New  York  Bar,     631 

B. 

Form  for  Recording  Cases  of  Insanity  to  Insure  Uniformity  of  Statistics,       .         .     672 

c. 

Resume  of  the  Treatment  of  Insanity,  ...,..,,.     675 

D. 

Explanation  of  Frontispiece,  ..........     679 

E. 

Bibliography,  .............     680 

Index, 693 


INTRODUCTION. 


A  PERFECT  state  of  the  organization  of  the  nervous  system  and 
freedom  from  any  pathological  condition  are  required  for  the  perfect 
performance  of  its  functions.  Any  pathological  state  of  the  brain 
or  spinal  cord  changes  the  normal  function  of  the  nervous  system 
and  produces  disease. 

The  seat  of  the  intellectual  and  emotional  functions  is  in  the  con- 
volutions of  the  cerebrum;  the  cerebellum  and  the  central  masses  of 
gray  matter  being  the  seat  of  motion,  which  may  be  excited  by  the 
desires  and  by  impressions  upon  the  sensory  and  excito-motory 
nerves.  The  medullary  substance  of  the  brain  is  but  a  series  of  con- 
ducting fibres,  and  pathological  conditions  of  the  white  substance  in 
the  cerebellum,  the  corpora  striata  and  thalami  frequently  exist  with- 
out affecting  the  mental  functions.  Such  diseases  will  affect  sensa- 
tion and  motion,  but  judgment,  memory,  and  emotion  will  probably 
be  left  unaffected.  Conversely,  disease  may  be  limited  to  portions  of 
the  brain  which  either  conduct  impressions  to  or  from  the  brain,  or 
which  subserve  the  function  of  muscular  activity.  We  may  have 
cerebral  paralysis  without  mental  disease,  although  an  effusion  of  blood 
in  the  white  substance  may  produce  loss  of  mental  function  when  it  at 
first  takes  place,  from  the  pressure  on  the  gray  matter  of  the  convolu- 
tions. The  mental  power  soon  returns,  however,  while  paralysis  of 
motion  remains  until  the  integrity  of  the  injured  brain-substance  is  re- 
stored. Pathological  states  of  either  the  gray  or  white  substance  of 
the  brain  often  extend  from  one  to  the  other  by  continuity  or  sympa- 
thy, as  they  are  so  intimately  connected,  although  differing  in  function. 

The  causes  of  diseases  of  the  nervous  system  are  like  the  causes 
of  all  diseases— predisposing  and  exciting.  The  first  or  predisposing 
cause  comprises  the  conditions  which  so  modify  the  health  of  a  person 
as  to  predispose  him  to  the  acquisition  of  nervous  diseases.  They 
are:  the  influence  of  age,  with  the  important  physiological  epochs 
that  pertain  to  the  different  periods  of  life ;  difference  in  the  organiza- 
tion of  the  sexes ;  personal  peculiarities,  comprising  the  influence 
of  heredity,  with  its  transmission  of  peculiarities,  tastes,  and  tendencies 
to  disease,  such  as  insanity,  epilepsy,  hysteria,  and  neuralgia;  occupa- 

3 


34  INTRODUCTION. 

tion,  habits  of  life,  and  effects  of  previous  disease,  which  man}-  times 
engender  a  liabiKty  to  recurrence  of  the  same  or  aUied  neuroses  ;  and, 
finally,  influence  of  climate  and  atmospheric  changes  and  temperature. 
The  second  or  exciting  causes  of  nervous  diseases  maybe  divided  into 
three  classes — mechanical,  chemical,  and  vital,  ist.  ]\Iay  be  mechan- 
ical, or  pertaining  to  abnormalities  in  anatomical  structure  of  the 
nervous  system  or  interference  with  it,  as  thickening  or  contraction 
of  bloodvessels  by  pressure  on  them  or  from  obstructions  in  them ; 
impediments  to  the  transmission  of  nerve  currents  along  the  nerves  ; 
dilatations  of  arteries,  and  extravasations  or  effusions  of  the  blood 
or  serum.  2d.  The  chemical  causes  of  ner\'ous  diseases  include  all 
that  may  be  traced  to  the  action  of  poisonous  substances,  whether 
derived  from  the  inorganic  or  organic  kingdoms  :  thus  muscular  tre- 
mors may  indicate  mercurialism  ;  and  dropped  hand,  lead  poisoning. 
The  effects  of  stimulants,  narcotics,  and  tobacco  are  also  included. 
The  retention  in  the  system  of  poisonous  effete  matter,  owing  to  the 
defective  action  of  the  excretory  organs,  are  among  the  most  impor- 
tant of  the  chemical  causes  of  nervous  disease,  and  depend  upon 
inefficient  action  of  the  kidne}'S,  liver,  lungs,  and  skin.  The  brain 
being  so  abundantly  supplied  with  bloodvessels,  is  liable  to  all  abnor- 
mal conditions  which  irregularity  in  the  quantity  or  quality  of  the 
blood  can  occasion.  It  is  exposed  to  the  effects  of  ansemia  and  h3''per- 
aemia,  the  latter  being  sometimes  accompanied  by  organizable  or 
inorganizable  exudates.  If  there  is  excess  of  carbonic  acid  or  defi- 
ciency of  oxygen  in  the  blood  circulating  through  the  brain,  it  is 
immediately  affected  by  it.  The  brain  is  also  disturbed  through  sym- 
pathy by  injuries  of  or  poisonous  influences  applied  to  the  peripheral 
portions  of  the  nervous  system.  3d.  The  z'ita/  causes  of  nervous  dis- 
eases are  those  which  implant  themselves  in  our  bodies,  and  grow 
and  multiply,  producing  certain  characteristic  symptoms.  They  may 
be  palpable,  actual,  living  objects,  as  parasitic  animals  and  vege- 
tables, or  they  may  be  the  infectious  matters  to  which  the  exanthe- 
matous  fevers  are  due ;  or  the  poison  of  malaria,  on  which  ague  and 
intermittent  fever  depend,  which  closely  resembles  the  contagia  of 
fever.  The  nervous  s}'stem  is  especially  liable  to  disease,  as  its 
supreme  controlling  centre,  the  brain,  is  liable  to  conditions  of 
exhaustion  to  a  greater  extent  than  any  other  organ  of  the  body. 
The  overtasked  brain  cannot,  as  can  other  organs,  gradually  gain  an 
increase  of  power  to  perform  its  task,  but  if  tasked  to  such  a  state  of 
exertion,  by  any  cause  or  set  of  causes,  that  such  exertion  fails  to  be 


INTRODUCTION.  35 

followed  by  sleep,  rapid  exhaustion  follows,  with  excitement  of, 
and  perhaps  irregular  and  disproportionate  activity  of  its  func- 
tions. The  brain-cells  derive  nutritive  renovation  from  the  blood 
principally  or  entirely  during  sleep,  and  anything  that  directly  inter- 
feres with  the  uniform  and  healthy  interchange  of  nutritive  plasma 
passing  from  the  vessels  to  the  cells,  and  of  the  fluid  cell-contents  in 
a  state  of  involution  or  degenerative  metamorphosis  passing  from  the 
cells  to  the  vessels,  deranges  the  intimate  connection  between  the 
nervous  and  vascular  systems  through  which  their  most  important 
functions  are  performed,  producing  at  once  grave  disturbances  of  the 
nervous  system,  which  may  eventuate  in  insanity.  The  elementary 
disturbances  of  the  cerebral  functions  which  we  meet  with  in  our 
clinical  studies  in  psychiatry,  involve  processes  in  the  emotional 
sphere;  processes  in  the  sphere  of  the  conceptions,  comprising  the 
reason,  memory,  and  phantasy;  and,  finally,  processes  in  the  psycho- 
motor sphere,  the  impulses,  and  the  will.  Among  emotional  disturb- 
ances we  find  the  two  extremes  of  morbid  depression  and  morbid 
exaltation,  and  also  the  conditions  of  abnormal  excitability  and 
abnormal  absence  of  emotion.  The  morbid  processes  in  the  con- 
ceptioftal  sphere  involve  and  affect  the  duration,  association,  intensity, 
and  reproduction  of  conceptions,  and  also  comprise  the  delusions  of 
the  insane,  or  false  conceptions.  The  morbid  processes  met  with  in 
the  psycho-motor  sphere  cause  the  morbid  desire  for  food  char- 
acterizing the  insane  and  the  refusal  of  food  by  melancholiacs ; 
affections  of  the  sexual  propensities,  either  loss  or  abnormal  excita- 
tion ;  the  various  morbid  impulses  associated  v/ith  insanity;  also,  dis- 
turbances in  speech.  We  have  elementary  disturbances  of  conscious- 
ness in  diseases  of  the  mind,  such  as  epileptic  states,  ecstasy, 
somnambulism,  various  states  of  altered  consciousness,  and  the 
bewildered  state  of  the  mind  in  paralytic  dementia.  We  have  also 
sensory  disturbances,  as  anaesthesia  and  hypersesthesia ;  motor  dis- 
turbances ;  vaso-motor  disturbances,  such  as  cerebral  anaemia,  cere- 
bral hyperaemia,  venous  stasis,  and  oedema  of  the  cortex,  and  a  great 
many  changes  in  arterial  tension,  resulting  in  sudden  cardiac  disturb- 
ances in  the  insane.  We  have  also  trophic  disturbances,  such  as  the 
herpes  and  rhagades  of  melancholiacs  and  patients  with  dementia; 
abnormal  pigmentations,  etc.  We  find  also  miany  anomalies  of  the 
vital  functions — the  temperature,  the  pulse,  digestion,  assimilation, 
respiration,  general  nutrition,  and  sleep. 

As  psychiatry  is  the  broadest  field  of  medicine,  and  is  beginning 


36  INTRODUCTION. 

to  attract  general  medical  attention,  and  as  we  must  look  to  the  gen- 
eral practitioners  for  practical  aid  in  stemming  the  great  and  growing 
tide  of  insanity,  and  depend  upon  their  intelligent  efforts  to  avert  it 
through  the  prevention  of  hereditary  transmission,  which  threatens 
family  deterioration,  this  book  is  presented  to  them  in  the  belief  that 
it  will  be  acceptable  to  them.  The  general  or  family  physician  is 
interested  in  the  early  recognition  and  repression  of  the  first  sign  of 
mental  disorder,  and  he  is  to  be  the  psychological  physician  of  the 
near  future. 

To  the  authors  of  those  works  quoted  or  to  which  I  have  referred, 
and  to  many  miscellaneous  writers  whose  writings  have  been  of  ser- 
vice to  me,  I  acknowledge  my  indebtedness,  and  especially  to  Mauds- 
ley,  J.  Russell  Reynolds,  J.  Hughlings  Jackson,  Drs.  Ramskill,  Char- 
cot, Bastian,  Duchenne,  Skey,  Radcliffe,  Begbie,  Trousseau,  Niemeyer, 
Bristowe,  Bouchard,  Romberg,  Lancereaux,  Moreau,  Goebel,  Brown- 
Sequard,  Wilks,  Broadbent,  Kirkes,  Rilliet  et  Barthez,  Durand-Fardel, 
Todd,  Doussin,  Maisonneuve,  Pritchard,  Falret,  Briquet,  Landouzy, 
Bucknill  and  Tuke,  Parchappe,  Griesinger,  Clouston,  Leidesdorf, 
Griffin,  Valleix  and  Remak,  Krafft-Ebing,  Esquirol,  and  Ray. 

Respecting  the  medical  treatment  of  insanity  in  our  public  institu- 
tions, I  would  say  that  I  deem  the  great  necessity  of  the  day  to  be  for 
greater  individual  consideration,  special  treatment,  and  remedial  care 
of  the  insane. 

The  theory  that  the  course  of  insanity  is  scarcely  ever  arrested  or 
shortened  ought  to  date  its  death-blow  from  1852,  when  the  eminent 
Dr.  Forbes  Winslow,  of  London,  England,  wrote  as  follows : 

It  is  a  lamentable  error  to  suppose — and  a  dangerous,  a  false,  and  unhappy  doctrine  to 
promulgate — that  the  disordered  affections  of  the  mind  are  not  amenable  to  the  recog- 
nized principles  of  medical  science.  I  again  declare  it  to  be  my  positive  and  deliberately 
formed  opinion  that  there  are  few  diseases  of  equal  magnitude  so  susceptible  of  success- 
ful medical  treatment  in  the  incipient  form  as  those  implicating  the  normal  action  of 
thought.  The  vast  amount  of  incurable  cases  of  insanity  which  crowd  the  wards  of  our 
national  and  private  asylums  is  pregnant  with  important  truths.  In  the  history  of  these 
unhappy  persons — these  lost  and  ruined*  minds — we  read  recorded  the  sad,  melan- 
choly, and  lamentable  i-esults  of  either  a  total  neglect  of  all  efficient  curative  treatment  at 
a  period  when  it  might  have  arrested  the  onward  advance  of  the  cerebral  mischief  and 
maintained  reason  upon  her  seat,  or  of  the  use  of  injudicious  and  unjustifiable  measures 
under  mistaken  notions  of  the  nature  and  pathology  of  the  disease.  ,In  no  class  of  affec- 
tions is  it  so  imperatively  necessary  to  inculcate  the  importance  of  early  and  prompt 
treatment  as  in  the  disorders  of  the  brain  affecting  the  manifestations  of  the  mind.  I  can- 
not close  my  eyes  to  the  fatal  consequences  which  have  so  often  ensued  from  a  belief  in 
the  incurability  of  insanity  by  medical  means.  In  all  grades  of  society  we  witness  the 
pernicious,  the  fatal,  the  disastrous  effects  of  this  dogma,  etf.,  etc. 


PSYCHOLOGICAL  MEDICLNE. 


CHAPTER  L 

HISTORY   AND    CLASSIFICATION    OF    INSANITY. 

The  earliest  mention  made  of  insanity  is  about  145 1  B.C.,  when 
Moses  declares  to  the  children  of  Israel  that  if  they  disobey  the  law 
given  to  them  they  will  be  smitten  with  madness.  David's  feigned 
insanity  occurred  about  the  year  1062  B.C.  He  evidently  simulated 
dementia  to  exempt  him  from  punishment  at  the  hands  of  Achish. 
Ulysses,  11 84  b.c,  feigned  madness  to  escape  service  in  the  Trojan 
war.  Euripides,  in  his  writings,  alludes  to  the  power  of  the  god 
Bacchus  to  produce  madness.  Cambyses  was  looked  upon  as  insane 
before  his  devastation  of  Egypt,  during  which  time  he  plunged  his 
dagger  in  the  sacred  bull  Apis,  for  which  sacrilege  he  was  divested 
of  all  reason.  Nebuchadnezzar,  the  great  Babylonian  king,  v/as  in- 
sane, and  left  the  haunts  of  men,  leading  the  life  of  a  beast, — a  form 
of  madness  called  lycanthropy.  The  ancients  from  their  descriptions 
were  acquainted  with  insanity,  and  the  earlier  Greek  historians  make 
mention  of  it  as  affecting  the  Greek  mythological  personages.  Thus 
Ajax  killed  all  the  sheep  in  the  camp,  under  the  delusion  that  they 
were  enemies,  and  favored  the  cause  of  his  rival  Ulysses.  Upon  re- 
covering his  reason  he  committed  suicide  through  mortification  at 
what  he  had  done.  Even  Hercules  was  said  to  suffer  from  insanity. 
Juvenal,  300  years  B.C.,  mentions  hellebore  in  his  writings  as  the 
specific  in  insanity,  and  it  was  by  this  remedy  that  Melampus  is  said 
to  have  cured  the  three  daughters  of  Proetus,  who  became  insane 
through  failure  to  worship  the  god  Bacchus.  The  heathen  philoso- 
phers believed  that  the  devil  took  up  his  abode  in  the  soul,  and  that 
the  insane  person  became  thus  possessed.  They  believed  that  he 
forced  an  entrance  into  the  soul  from  without  the  body.  Although  in 
the  New  Testament  we  find  accounts  of  insanity,  possession  of  the 
devil  was  regarded  as  synonymous  with  lunacy.     In  Matthew  4  :  24, 


38  PSYCHOLOGICAL    MEDICINE. 

the  Apostle  distinctly  says  that  they  brought  to  Christ,  those  who 
were  lunatic  and  those  who  had  the  palsy;  and  he  healed  them. 
From  the  earliest  period  in  the  history  of  medicine  mental  diseases 
have  been  recognized,  more  or  less  classified,  and  treated  as  a  rule 
as  worthy  of  the  utmost  attention  that  science  and  humanity  could 
dictate.  As  far  back  as  the  days  of  Hippocrates,  insanity  was 
recognized  as  appearing  under  different  forms  and  conditions  of 
mind. 

Hippocrates,  in  writing  of  insanity,  mentioned  three  states  in  which 
mental  disease  was  manifested  :  mania,  melancholia,  and  dementia. 
Celsus  also  recognized  three  kinds  of  insanity.  The  old  Roman 
laws  divided  the  insane  into  two  classes  :  furiosi,  those  who  were  vio- 
lent and  maniacal;  and  meiite  r^a/z'/,  those  who  were  suffering  from 
dementia,  or  weakness  of  intellect.  The  ancient  writers,  although 
very  crude  in  their  ideas  of  insanity,  recognized  as  a  rule  the  differ- 
ent mental  states  accompanying  mania,  melancholia,  and  dementia. 
Different  writers  in  modern  times  have  attempted  various  methods 
of  classification,  but  the  simple  and  yet  comprehensive  one  of  Pinel 
has  really  been  the  foundation-stone  on  which  all  succeeding  writers 
have  reared  their  modern  systems  of  classification.  The  classification 
just  alluded  to  includes  the  four  great  primary  mental  states  or  con- 
ditions of  insanity,  namely :  mania,  melancholia,  dementia,  and 
idiocy.  As  most  writers  on  insanity  prefer  to  enlarge  on  such  simple 
classifications  and  elaborate  them  somewhat,  the  question  arises,  what 
are  the  best  grounds  on  which  to  found  our  classification  ?  This 
question  has  been  ably  answered  by  many  writers.  The  aetiology 
or  causes  of  insanity  has  been  made  the  basis  of  two  very  excellent 
classifications,  the  first  by  Dr.  Morel  in  his  Traite  des  Maladies  Men- 
talcs,  published  in  i860,  and  the  second,  a  later  and  more  elaborate 
one,  by  Dr.  Skae.  The  International  Congress  of  Alienists,  at  their 
meeting  in  Paris,  in  18-67,  adopted  a  combination  of  the  setiological 
and  symptomatological  methods  under  seven  heads :  i.  Simple  in- 
sanity. 2.  Epileptic  insanity.  3.  Paralytic  insanity.  4.  Senile  de- 
mentia. 5.  Organic  dementia.  6.  Idiocy.  7.  Cretinism.  Drs. 
Bucknill  and  Tuke,  in  their  Mamtal  of  Psychological  Mediciiie,  have 
adopted  a  combination  of  the  symptomatological  and  psychological 
method  of  classification.  They  have  divided  it  under  five  heads  or 
divisions,  as  follows : 

I.  Idiocy,  imbecility,  and  cretinism ;  states  of  undeveloped  intel- 
lectual power. 


HISTORY    AND    CLASSIFICATION    OF    INSANITY.  39 

II.  Dementia ;  a  state  in  which  the  intellectual  power  has  been 
destroyed. 

III.  Delusional  insanity  ;  under  which  head  they  embrace  all  the 
states  in  which  marked  delusions  are  present — melancholia,  with 
delusions ;  monomania,  with  delusions ;  and  homicidal  and  suicidal 
insanity,  with  delusions. 

IV.  Emotional  insanity,  or  morbid  states  of  the  emotions  without 
delusion,  whether  attended  by  melancholia  or  excitement. 

V.  Mania.  In  conclusion  it  is  remarked  that  "  all  these  forms  or 
varieties  of  insanity  are  liable  to  complication  with  epilepsy,  or,  if 
acquired,  with  general  paralysis." 

In  moral  and  intellectual  idiocy,  and  imbecility,  and  cretinism,  we 
find  an  absence  or  arrest  of  the  development  of  the  intellectual  and 
moral  faculties,  while  cretinism  is  characterized  also  by  a  character- 
istic vicious  conformation  of  the  body — an  arrest  of  development  of 
both  body  and  brain  alike. 

We  have  mania  from  many  causes.  We  find  hysterical  mania, 
amenorrhoeal  mania,  puerperal  mania,  the  mania  of  pregnancy  and  of 
lactation ;  climacteric  mania,  occurring  at  the  change  of  life ;  mania 
due  to  ovarian  or  uterine  disease;  senile  mania;  phthisical  mania; 
metastatic  mania;  traumatic  mania;  syphilitic  mania ;  delirium  tre- 
mens, and  dipsomania ;  together  with  the  distinct  mania  of  alcohol- 
ism, mania  after  fevers,  mania  depending  upon  oxaluria  and  phos- 
phaturia,  general  paralysis  with  mania,  and  idiopathic  mania.  These 
different  forms  of  mania  do  not  necessarily  have  their  own  special 
psychological  character,  because,  for  instance,  in  puerperal  insanity 
we  may  find  in  one  case  melancholia  as  the  mental  state,  and  in 
another  case  mania.  It  is  important  in  studying  mental  disorders — 
in  treating  them,  also — to  look  to  the  bodily  origin  of  the  disease 
and  remove  the  morbid  condition  upon  which  the  insanity  often 
entirely  depends.  We  must  be  careful,  however,  not  to  ignore  psy- 
chical causes  of  insanity,  as  mania  has  frequently  an  emotional  as 
well  as  a  physical  cause. 

Metaphysically  speaking,  ist.  Insanity  affects  the  intellect  or  the 
ideas;  2d.  The  feelings  and  moral  sentiments;  and  3d.  The  propen- 
sities or  instincts. 

Among  the  curable  forms  of  insanity  we  have  the  insanity  of  preg- 
nancy, insanity  of  childbirth,  insanity  of  lactation,  climacteric  insanity, 
insanity  from  uterine  disorder,  insanity  from  tuberculosis  (?),  insanity 


40  PSYCHOLOGICAL    MEDICINE. 

from  masturbation,  insanity  from  alcoholism,  delirium  tremens,  dip- 
somania, hysterical  insanit}',  and  post-febrile  insanity. 

The  forms  of  insanit}"  generally  styled  incurable  include  paralytic 
insanity,  epileptic  insanity,  senile  dementia,  and  organic  dementia. 
Dr.  Auguste  Voison,  however,  takes  an  altogether  more  hopeful 
view  than  is  held  by  the  profession  generally  of  the  curability  oi gen- 
eral paralysis,  even  in  confirmed  cases,  and  reports  ten  cures  on 
record  where  there  could  be  no  doubt  of  the  diagnosis. 

In  treating  of  the  pathology'  and  therapeutics  of  cerebral  disease, 
we  may,  I  think,  advantageously  combine  a  method  alike  adapted  to 
the  student  of  medicine  and  to  the  general  practitioner,  combining  a 
classification  which,  although  it  is  artificial,  aims  at  presenting  to  the 
view  a  series  of  mental  pictures  displaying  certain  types  or  forms  of 
disease  and  such  canons  of  treatment  as  may  remain  in  the  memory 
and  constitute  starting-points  for  subsequent  illustration  and  investi- 
gation, with  a  mode  based  on  clinical  experience,  which,  even  though 
it  fails  perhaps  to  corroborate  the  dicta  of  nosologists,  is  equally 
valuable. 

I  have  aimed  to  teach  the  necessity  of  examining  carefully  ever}"- 
case  as  it  arises,  and  not  to  accept  blindly  and  bind  the  mind  down 
to  any  preconceived  ideas  derived  from  the  authority  of  books,  how- 
ever well  written.  3.1y  experience  in  the  treatment  of  diseases  of  the 
mind  and  nervous  system  has  convinced  me  of  the  fallacy  of  almost 
all  our  attempts  to  establish  unerring  principles  of  nosological  ar- 
rangement or  to  establish  dogmatic  principles  of  treatment.  For  the 
student  of  mental  disease  who  desires  to  study  a  classification  of 
insanit}',  I  present  the  classification  of  one  of  the  most  eminent  teach- 
ers of  clinical  psychiatry  in  Germany,  and  one  of  the  most  eminent 
of  the  new  school  of  German  alienists,  Professor  Krafft-Ebing. 

His  fundamental  classification  of  the  insanities  is  into  the  psycho- 
neuroses  and  the  psychical  degenerative  .states,  and  to  this  he  adds,  as 
equivalent  groups,  the  cerebral  diseases  associated  with  predominat- 
ing psychical  symptoms  and  the  conditions  of  arrested  development. 

Classification  of  Insanity. 
The  Psycho-neuroses. 

I.  Primary  curable  forms. 
A.  Melancholia. 

1.  Melancholia. 

2.  ^Melancholia  attonita. 


HISTORY    AND    CLASSIFICATION    OF    INSANITY,  4 1 

B.  Mmiia. 

1.  Simple  maniacal  excitement. 

2.  High   maniacal  exaltation,  with  great  motor  excite- 

ment and  often  with  furor. 

C.  Primary  dementia  [StupiditcEt). 

11.  Secondary  incurable  conditions  of  psychical  weakness. 

A.  Chronic  mania,  with  a  loss  of  power  of  creating  systematic 

delusions,  found  as  a  sequel  of  uncured  primary  forms 
{Sec2mdiBre  verruecktheit) . 

B.  Terminal  dementia. 

1.  Dementia,  with  excitement  and  confusion. 

2.  Apathetic  dementia. 

Tlie  Psychical  Degenerative  States. 

A.  Constitutional  affective  insanity  [Folic  Raissormante). 

B.  Moral  insanity. 

C.  The  monomanies,  or  Folie  systematisee  {Primcere  Verruecktheii), 

1.  With  delusions. 

a.  Of  persecution. 

b.  Megalomania. 

a.  in.  Religiosa. 

b.  in.  Erotica. 

2.  With  imperative  conceptions  [Zivangsvorstelhingen). 

D.  Epileptic  insanity. 

1.  The  psychical  degenerations  of  epileptics,  or  ep.  dementia. 

2.  The  transitory  epileptic  psychical  disturbances  which  pre- 

cede, or  follow,  or  take  the  place  of  convulsions. 

a.  Epileptic  stupor. 

b.  States  of  imperfect  and  dazed  consciousness. 

a.  With  fright  {petit  nial  intellectual). 

b.  With  frightful  deliria  and  hallucinations  {grand 

mal  intellectual). 

c.  With  religiously  expansive  deliria. 

d.  Dreamy  stupor. 

e.  Dreamy  stupor,  with  excitement. 

3.  The  epileptic  psychoses. 

E.  Hysterical  insanity. 

I.  Transitory  forms. 

a.  With  fright. 

b.  Hystero-epileptic  deliria. 


42  PSYCHOLOGICAL    MEDICINE. 

c.  Ecstatic  visionary  forms. 

d.  Moria-like  conditions. 
2.  Chronic  forms. 

a.  Hystero-melancholia. 

b.  Hystero-mania. 

c.  Degenerative  states,  with  hysterical  basis. 

F.  Hypochondriacal  insanity. 

G.  Periodical  insanity. 

I.   Of  idiopathic  origin. 

1.  In  the  guise  of  a  psycho-neurosis. 

a.  Mania  periodica. 

b.  Dipsomania. 

c.  Melancholia  periodica. 

d.  Circular  insanity. 

2.  In  the  guise  of  delirium. 
II.   Of  sympathetic  origin. 

a.  Periodical  insanity  of  menstruation. 

TJie  Cerebral  Diseases  zvith  Predominating  Psychical  Symptoms. 

A.  Dementia  paralytica  [Progressive  paresis). 

B.  Cerebral  syphilis. 

C.  Chronic  alcoholism  and  its  complications. 

1.  Delirium  tremens. 

2.  Pathological  intoxications  [mania  a  potii). 

3.  Hallucinatory  conditions. 

4.  The  alcoholic  psychoses. 

a.  Mania  gravis  potatorum. 

b.  Alcoholic  melancholia. 

c.  Alcoholic  insanity,  with  delusions  of  persecution. 

d.  Alcoholic  paralysis. 
5-  Alcoholic  epilepsy. 

D.  Senile  dementia. 

E.  Acute  delirium  [Congestive  mania  and  typho-manid). 

The  Psychical  States  of  Arrested  Development — Idiocy  and  Cretinism. 

It  should  be  understood  that  the  psycho-neuroses  are  those  insani- 
ties which  attack  an  intact  brain,  and  the  psychical  degenerative 
states  are  those  affecting  the  brain  injured  by  hereditary  or  acquired 
vices  of  conformation  or  mal-nutrition. 


HISTORY   AND    CLASSIFICATION    OF    INSANITY.  43     ^ 

In  our  examination  and  study  of  cases  of  insanity  we  may  with 
advantage  take  up, 

1.  Anthropometry,  or  study  of  the  cranium. 

2.  The  face :  physiognomy,  breadth  of  forehead,  shape  of  ears. 

3.  The  trunk  :  shape  of  thorax,  muscular  development,  amount  of 
adipose  tissue. 

4.  Upper  limbs  :  comparison,  abnormal  states,  etc. 

5.  Lower  limbs  :  size  of  muscles  and  symmetry. 

6.  Psychical  functions:  ideation;  memory;  language,  whether 
defective  or  not ;  neatness  of  pronunciation. 

7.  Functions  of  relation  :  sensibility — tactile,  dolorific,  and  ther- 
mal, electric  sensibility ;  the  special  senses ;  mobility  of  pupils ; 
paresis  or  paralysis. 

8.  Vegetative  functions,  whether  normally  performed. 

9.  Examination  of  urine. 

In  making  autopsies  in  cases  of  insanity,  we  should  examine, 

1.  Cranium:  the  bony  case,  whether  thick  or  thin.  Diploe ;  lon- 
gitudinal suture,  Avhether  straight,  or  turning  to  right  or  left. 

2.  Cerebrum :  conformation  and  development  of  hemispheres, 
whether  alike  in  size.  Dura  mater  and  pia  mater,  whether  adherent 
to  hemispheres.  Vessels  of  the  pia  mater,  whether  injected  beyond 
normal.  Convolutions,  whether  developed  sufficiently,  particularly 
the  ascending  parietal  and  the  ascending  frontal.  In  epilepsy  the 
most  internal  part  of  the  ascending  parietal  has  been  found  to  be 
atrophied  and  indurated  to  cartilaginous  consistence  as  far  as  its  em- 
brochure  in  the  fissure  of  Sylvius  ;  also,  the  ascending  frontal  and 
foot  of  the  third  frontal.  Base  of  the  cerebrum  :  open  lateral  ventri- 
cles and  examine  thalami  optici  and  corpora  striata.  Weight  of 
hemispheres. 

3.  Mesocephalon  :  cerebral  peduncles,  pons,  medulla,  hemispheres 
of  cerebellum. 

4.  Medulla  spinalis :  comparison  of  two  halves. 

5.  Thorax;  lungs;  bronchi;  heart,  aortic  walls  for  atheroma; 
valves  of  heart. 

6.  Abdomen;  liver,  size,  consistence,  anaemic  or  congested,  etc.; 
spleen,  size  and  consistence ;  kidneys,  size,  glomeruli  and  pyramidal 
substance  ;  gastro-intestinal  tract. 

7.  Microscopic  examination  of  brain. 

Definitions  of  Insanity. — It  is  almost  impossible  to  give  a  good 
definition  of  insanity.     Many  have  endeavored  to  do  so,  but  none  of 


44  PSYCHOLOGICAL    MEDICINE. 

them  have  as  yet  succeeded.  Locke  said  that  "madmen  do  not 
appear  to  have  lost  the  faculty  of  reasoning,  but  having  joined  to- 
gether some  ideas  very  strongly,  they  mistake  them  for  truths  and 
err  as  men  do  who  argue  from  wrong  principles." 

Cullen  called  insanity  a  "lesion  of  the  intellectual  faculties  without 
pyrexia  and  without  coma." 

Dr.  Combs's  definition  of  insanity,  was,  that  "  it  is  a  prolonged 
departure,  and  without  an  adequate  external  cause,  from  the  state  of 
feeling  and  modes  of  thinking  usual  to  the  individual  who  is  in  health, 
that  is  the  true  feature  of  disorder  of  mind."  He  also  speaks  of 
insanity  as  "  a  morbid  action  in  one,  in  several,  or  in  the  whole  of  the 
cerebral  organs,  and,  as  its  necessary  consequence,  functional  de- 
rangement in  one,  in  several,  or  in  the  whole  of  the  mental  faculties 
which  these  organs  subserve." 

Dr.  Conolly  says  :  "  Insanity  is  an  impairment  of  one  or  more  of 
the  faculties  of  the  mind,  accompanied  with  or  inducing  a  defect  in 
the  comparing  faculty." 

Guislain  says :  "  Insanity  is  a  derangement  of  the  mental  faculties 
— morbid,  apyrexial,  and  chronic — which  deprives  man  of  the  power 
of  thinking  and  acting  freely  as  regards  his  happiness,  preservation, 
and  responsibility." 

Morel  says :  "  Insanity  is  a  cerebral  affection,  idiopathic  or  sym- 
pathetic, destroying  the  individual's  moral  liberty  and  constituting  a 
derangement  of  his  acts,  tendencies,  and  sentiments,  as  well  as  a 
general  or  partial  disorder  in  his  ideas." 

Dr.  Bucknill  says  :  "  Insanity  is  a  condition  of  the  mind  in  which 
a  false  action  of  conception  or  judgment,  a  defective  power  of  the 
will,  or  an  uncontrollable  violence  of  the  emotions  and  instincts  have 
separately  or  conjointly  been  produced  by  disease." 

It  is  very  much  easier  to  describe  than  to  define  insanity.  A  fair 
medico-legal  definition  may  be  found,  however,  I  think,  in  the  fol- 
lowing: Insanity  is  a  disease  of  the  body  affecting  the  mind  by  de- 
ranging its  faculties  and  causing  such  suspension  or  impairment  of 
the  action  of  the  healthy  intellect,  emotions,  or  the  will,  as  to  render 
the  individual  irresponsible. 

Ancient  and  Modern  Classifications. — It  is  understood  that  Hippoc- 
rates recognized  mania,  melancholia,  and  dementia,  although  he  did 
not  classify  insanity  in  this  manner. 

Celsus  recognized  phrenitis,  accompanied  by  fever,  as  one  form  of 
insanity;  second,  mental  disturbances  without  fever,   characterized 


HISTORY   AND    CLASSIFICATION    OF    INSANITY.  45 

by  melancholy  and  caused  by  black  bile  ;  and  third,  a  form  which 
he  separated  in  two  subdivisions,  "  for  some  err  in  having  false 
images,  and  not  in  their  whole  mind,  as  Ajax  and  Orestes  are  repre- 
sented in  poetic  fables;  in  others,  the  whole  mind  or  judgment  is 
affected." 

Aretseus  recognized  mania,  melancholia,  and  dementia,  but  con- 
sidered melancholia  as  only  the  initial  stage  of  mania. 

Ca^lius  Aurelianus  recognized  mania  and  melancholia  as  the  two 
forms  of  insanity. 

Galen  classified  insanity  into  amentia,  imbecility,  mania,  and  melan- 
cholia. 

Sauvages,  in  1763,  wrote  on  the  "  vesanicB,"  which  he  subdivided 
into  the  halhicinationes,  inorositatcs,  and  deliria. 

Linnaeus,  in  1763,  wrote  on  i\].e''  mentales,"  and  psychologically 
divided  them  into  the  three  classes  of  the  ideales,  imaginarii,  and 
pathetici. 

Vogel,  in  1764,  recognized  mania,  melancholia,  and  amentia. 

Cullen  placed  insanity  in  the  class  Neuroses  and  under  the  order 
Vesanice.  His  four  great  divisions  were  amentia,  melancholia,  mania, 
and  oneirodinia.  This  last  division  included  sornnambulism  and 
nightmare. 

Dr.  Arnold,  in  1782,  divided  insanity  into  ideal,  notional,  and 
pathetic  insanity. 

Crichton,  in  1798,  adopted  Cullen's  method  of  placing  mental  dis- 
eases in  the  class  Neuroses  and  under  the  order  Vesanics,  and  divided 
the  latter  into  delirium,  hallucinatio,  and  amentia. 

Mason  Good  made  the  order  Phrenetica,  in  the  class  Neurotica,  and 
subdivided  it  into  ecphronia  (mania  and  melancholia),  empathema  (un- 
governable passion),  alusia  (illusion),  aphelexia  (reverie),  paronina 
(sleep  disturbance),  and  vioria  (fatuity). 

Pinel  divided  insanity  symptomatologically  under  the  four  divi- 
sions of  mania,  melancholia,  dementia,  and  idiotism.  He  used  the 
term  idiotism  as  indicating  an  advanced  dementia. 

Esquirol,  the  pupil  of  Pinel,  thus  divides  and  classifies  insanity: 

"  I.  Lypcmania  (melancholy  of  the  ancients):  disorder  of  the 
faculties  with  respect  to  one  or  a  small  number  of  objects,  with  pre- 
dominance of  a  sorrowful  and  depressing  passion. 

"2.  Monomania:  in  which  the  disorder  of  the  faculties  is  limited 
to  one  or  a  small  number  of  objects,  with  excitement  and  predomi- 
nance of  a  gay  and  expansive  passion. 


46  PSYCHOLOGICAL    MEDICINE. 

"3.  Mania:  in  which  the  delirium  extends  to  all  kinds  of  objects 
and  is  accompanied  by  excitement. 

"  4.  Dementia :  in  which  the  insensate  utter  folly,  because  the 
organs  of  thought  have  lost  their  energy  and  the  strength  requisite 
for  their  functions. 

"  5.  Imbecility  or  idiocy:  in  which  the  conformation  of  the  organs 
has  never  been  such  that  those  who  are  thus  afflicted  can  reason 
justly." 

Guislain  classified  insanity  as  follows  : 

Phrenalgia  or  melancholy ;  phrenoplexia  or  ecstasy ;  hyperphre- 
nia  or  mania  ;  paraphrenia  or  folly ;  ideophrenia  or  delirium  ;  aphre- 
nia  or  dementia. 

Dr.  Conolly  writes  of  insanity  under  Pinel's  heads  of  mania,  mel- 
ancholia, dementia,  and  idiocy,  etc.,  and  says  that  insanity  is  de- 
pendent upon  "  a  state  of  increased,  or  diminished,  or  unequal 
excitement  of  the  nervous  system." 

Professor  Laycock  makes  a  physiological  classification,  and  his 
principle  is  that  the  order  of  morbid  phenomena  of  insanity  is  similar 
and  identical  with  that  of  healthy  phenomena  modified,  and  patho- 
logical facts  should  be  classified  in  the  same  way  as  the  physiologi- 
cal. He  wrote,  therefore,  on  disease  of  "  (l)  The  encephalic  centres 
subservient  to  the  instincts  and  animal  propensities,  /.  e.,  the  medulla 
oblongata,  cerebellum,  and  posterior  lobes  of  hemispheres  ;.  (2)  Those 
centres  subservient  to  the  emotions  and  sentiments,  /.  c,  the  ideagenic 
or  sensorial  substance  of  the  cerebellum  and  hemispheres;  and  (3) 
Those  subservient  to  the  knowing  and  representative  faculties  (intel- 
lect), i.  t\,  the  nerves  of  the  senses,  their  ganglia,  and  the  ideational 
centres  in  the  cerebral  (and  cerebellar?)  hemispheres.  Imbecility, 
melancholia,  mania,  etc.,  characterize  defective  or  morbid  states  of 
the  structure,  and  therefore  of  the  function  of  the  localities  men- 
tioned."* 

]\I.  Parchappe's  classification  of  insanity  was  founded  on  pathology 

*  Bucknill  and  Tuke  suggest  that  if  physiological  and  psychological  functions  of  the 
brain  are  only  diS"erent  aspects  of  the  same  anatomical  substrata,  we  might  classify  men- 
tal disorders  in  two  great  divisions,  Sensory  Psychoses  and  Alotor  Psychoses.  The  former 
including  all  forms  of  insanity  in  which  feeling  and  emotion  and  the  power  of  sensory 
perception  and  ideation  are  more  particularly  involved  (hallucinations  and  conduct  de- 
termined thereby),  the  posterior  parts  of  the  brain  being  the  centres;  while  \h^  Alotor 
Psychoses  would  comprise  those  forms  in  which  the  higher  intellectual  faculties  are 
affected  as  afto  motor  power,  the  anterior  lobes,  here,  being  in  all  probability  the 
centres. 


HISTORY   AND    CLASSIFICATION    OF    INSANITY.  47 

alone,  as  follows  :  Monomania,  acute  mania,  acute  melancholia,  in- 
sanity with  paralysis,  insanity  with  epilepsy,  and  chronic  insanity. 

M.  Aug.  Voison  classifies  insanity  also  on  a  pathological  basis. 

Among  the  German  alienists,  Heinroth,  Ideler,  and  Hoffbauer 
classify  insanity  psychically,  while  others  classify  it  somatically.* 

Dr.  Pritchard  classified  insanity  psychologically,  and  divided  men- 
tal disorders  into  two  great  groups.  The  first  embraced  moral  in- 
sanity, or  pathomania;  the  second,  intellectual  insanity,  comprising 
monomania,  mania,  incoherence,  or  dementia. 

Dr.  Noble  and  Dr.  Henry  Mones  adopted  a  classification  of 
insanity,  ranging  it  in  three  classes — emotional,  notional,  and  intelli- 
gential. 

Griesinger  wrote  on  the  basis  of  psychology,  and  made  two  great 
divisions— Emotional  and  Intellectual  disorders,  and  associated  the 
will  under  the  last  head.  Three  states  were  recognized, — the  state  of 
mental  depression,  or  melancholia;  the  state  of  mental  exaltation; 
and  the  state  of  mental  weakness.  Under  the  first  state  Griesinger 
put  hypochondriasis,  simple  melancholia,  melancholia  with  stupor, 
melancholia  with  destructive  tendencies,  melancholia  with  persistent 
excitement  of  the  will ;  under  the  second  state,  mania  and  monoma- 
nia ;  and  under  the  third  state,  chronic  mania,  dementia,  idiocy,  and 
cretinism.  Also  disorders  of  sensation  and  sensations  of  movement 
were  treated  of 

Dr.  Maudsley's  mode  of  classifying  insanity  was  formerly  to  dis- 
tinguish the  two  great  classes  of  intellectual  or  ideational,  and  the 
emotional  or  affective.  Under  the  first  head  he  placed  mania,  mel- 
ancholia, monomania,  dementia,  general  paralysis,  idiocy,  and  imbe- 
cility; under  the  second  head  he  placed  maniacal  perversion  of  the 
affective  life  or  mania  sine  delirio,  melancholic  depression  without 
delusion  (simple  melancholia),  and  moral  alienation  proper,  in  close 
contiguity  to  which  is  the  insane  neurosis  of  some  families.  More 
lately,  however,  we  believe  he  has  adopted  Dr.  Skae's  classification, 
founded  upon  causes.  Dr.  Skae's  classification  is  as  follows — Dr. 
Clouston,  by  the  way,  designates  it  as  a  system  founded  upon  the 
principle  of  "  the  exclusion  of  everything  mental  or  psychical  con- 
nected with  insanity."  The  first  group  in  this  classification  is  Moral 
and  Intellectual  Idiocy  and  Imbecility;  the  second  is  Epileptic  Insan- 
ity; the  third,  Insanity  of  Masturbation;  the  fourth,  of  Pubescence. 

*  Max.  Jacobi,  Ilasse  and  Friedrich. 


48  PSYCHOLOGICAL    xMEDICIXE. 

Then  follow: 

Hysterical  mania. 

Amenorrhceal  mania. 

Post-connubial  mania. 

Puerperal  mania. 

Mania  of  pregnancy. 

Mania  of  lactation. 

Climacteric  mania. 

Ovario  mania  (utero  mania). 

Senile  mania. 

Phthisical  mania. 

^Metastatic  mania. 

Traumatic  mania. 

Syphilitic  mania. 

Delirium  tremens. 

Dipsomania. 

Mania  of  alcoholism. 

Post-febrile  mania. 

Mania  of  oxaluria  and  phosphaturia. 

General  paralysis,  with  insanity. 

Epidemic  mania. 

^  .     r  Sthenic, 
Idiopathic^    ,    ^, 

^  [  x\sthenic. 

Dr.  Skae  was  right  in  this  classification  in  so  far  that  he  recog- 
nized that  insanity  exists  only  as  the  result  of  disease,  either  func- 
tional or  organic,  in  some  part  of  the  human  body ;  but  he  was  wrong 
in  that  he  claimed  that  each  of  these  groups  presented  psychological 
features  peculiar  to  and  characteristic  of  it,  and  he  was  also  wrong 
in  ignoring  the  psychical  or  emotional  causes  of  insanity,  which  I 
consider  very  numerous,  and  which  act  with  great  virulence  on  a 
brain  at  all  weak  in  its  natural  development  or  in  one  in  whose 
family  insanity,  epilepsy,  or  consumption  is  to  be  found,  i.  e.,  in  a 
brain  not  perfectly  intact,  but  injured  by  a  hereditar}^  vice  of  nutri- 
tion. If  Dr.  Skae  had  added  a  group  of  psychical  or  emotional 
insanity,  and  had  omitted  the  claim  of  "  psychological  lineaments  " 
for  each  group,  he  would  have  given  psychologists  a  strong  classifi- 
cation.    As  it  is,  he  has  not.*     We  cannot  ignore  psychic  causes  in 

*  As  ^ve  naturally  take  the  full  history  of  every  patient  into  account,  as  well  as  the 
existing  mental  symptoms,  I  think  Dr.  Skae's  classification  practically  useful,  as  it  directs 
our  attention  to  the  bodily  cause  of  the  patient's  insanity  which  it  must  be  our  aim  to 


HISTORY   AND    CLASSIFICATION    OF    INSANITY.  49 

the  classification  of  insanity.  One  great  predisposing  cause  of  in- 
sanity is  the  insane  diathesis,  so  that  a  comparatively  slight  exciting 
cause  will  precipitate  mental  disease  upon  such  a  person.  The 
insane  diathesis  itself  is  not  a  disease,  but  rather  the  existence  of  the 
constitutional  tendency  to  it.  We  can  recognize  this  neurotic  dia- 
thesis, Dr.  Anstie  tells  us, 

"  I.  By  the  premature  occurrence  of  puberty.     Sexual  precocity. 

"  2.  By  the  unexpected  development  of  intense  artistic  feeling  in 
children  born  of  a  naturally  commonplace  family. 

"  3.   Convulsions  during  teething  without  adequate  cause. 

"4.  The  development  of  a  habit  of  lying  and  stealing  in  well- 
trained  children." 

Dr.  Anstie  thinks  that  an  active  hereditary  insane  neurosis  always 
originates  in  a  family  stock  from  either  drink,  sexual  excesses,  habit- 
ual want,  or  from  mental  vacuity  from  entire  want  of  education. 

In  Bucknill  and  Tuke's  Manual  of  Psychological  Medicine  both  Dr. 
Tuke  and  Dr.  Bucknill  give  their  own  classifications.  Dr.  Tuke 
gives  two,  the  first  a  classification  on  a  metaphysical  basis,  embracing 
three  great  classes:  i.  The  intellect  or  the  ideas  (intellectual  insanity); 
2.  The  feelings  and  the  moral  sentiments ;  and  3.  The  propensities 
(or  will),  instincts,  or  desires,  the  two  latter  classes  coming  under  the 
general  head  of  emotional  and  volitional  insanity.  The  second  clas- 
sification is  one  from  a  somato-aetiological  point  of  view,  and  this 
Tuke  prefers  himself  as  the  more  practical  working  classification. 
He  says  that  "  under  the  first  division  of  the  following  list  of  forms 
of  insanity  we  ought,  therefore,  to  recognize  a  number  of  important 
cases  which  arise  from  excessive  action  or  otherwise  of  the  mental 
functions  themselves,  the  brain  being  injured  thereby.  We  might, 
perhaps,  comprise  this  class  in  the  general  term,  'psycho-cerebral 
insanity,'  or  psychic  insanity.  Under  this  head  would  come  acute 
dementia  induced  by  mental  shock,  as  fright ;  insanity  induced  by 
excessive  study,"  etc.     The  following  is  the  classification : 

remove.  We  can  then  investigate  as  to  whether  disease  has  attacked  an  intact  brain  or 
one  predisposed  to  insanity  by  reason  of  inherited  or  acquired  vices  of  nutrition  or  con- 
formation, and  finally  investigate  the  psychical  state,  and  by  observing  the  state  of  mental 
exaltation,  depression  or  weakness  in  our  patient,  diagnose  the  case  as  one  of  melancholia, 
mania  or  dementia,  or  idiocy,  as  the  case  may  be.  We  have  to  consider  the  indications 
presented  in  each  individual  constitution.  We  must  know  the  present  state  of  the 
patient's  mind,  homicidal  or  suicidal,  etc.,  and  as  the  result  of  some  practical  experience 
the  author  of  this  work  does  hot  adopt  any  one  classification  exclusively,  and  does  not 
recommend  the  general  practitioner,  for  whom  this  work  is  especially  intended,  to  do  so. 
It  is  practically  impossible. 

4 


50  PSYCHOLOGICAL   MEDICINE. 

I.  Insanity  or  Mental  Deficiency  caused  by  Primary  Disease  or  Defective 

Development  of  the  Encephalic  Centres  [Protopathic  hisanity). 

1.  Congenital  or  infantile  deficiency. 

2.  Traumatic  insanity. 

3.  General  paresis. 

4.  Paralytic  insanity  (insanity  with  ordinary  paralysis). 

5.  Epileptic  insanity  (when  of  central  origin). 

6.  Senile  insanity  (insanity  from  old  age). 

II.  Insanity  caused  by  Disorder  of,  or  Developmental  Changes  occur- 

ring in  other  Organs  than  the  Encephalic  Centres  {Deuteropathic 
Insanity). 

7.  Pubescent  insanity. 

8.  Masturbatic  insanity. 

9.  Uterine  and  ovarian  insanity  (in  early  or  later  life). 

10.  Hysterical  insanity. 

11.  Insanity  of  gestation  or  pregnancy. 

12.  Puerperal  insanity  (proper). 

13.  Insanity  of  lactation. 

14.  Climacteric  insanity. 

15.  Intestinal,  vesical,  and  hepatic  insanity. 

16.  Post- febrile  insanity. 

17.  Rheumatic  and  choreic  insanity.     Gouty  insanity? 

18.  Tubercular  insanity. 

19.  Syphilitic  insanity. 

III.  htsanity  caused  by  Alcohol  and  other  Poisons  {Toxic  Insanity). 

20.  Alcoholic  insanity. 

21.  Pellagrous  insanity, 

22.  Cretinism. 

"  Insanity  may  be  epidemic.  With  any  of  the  foregoing  may  be 
associated,  as  a  predisposing  cause,  the  insane  diathesis." 

The  above  classification  of  mental  disorders  from  the  purely 
somato-setiological  point  of  view  is  very  excellent.  It  is  an  ap- 
proach to  an  anatomo-pathological  classification,  but  perhaps  lacks 
the  psychological  method.  It  is,  however,  in  strict  conformity  with 
the  somatic  school  of  German  psychology  represented  by  Max  Jacobi, 
Nasse,  and  Friedrich. 

Clinically,  when  we  have  a  case  of  insanity  to  deal  with  we  natu- 


HISTORY   AND    CLASSIFICATION    OF    INSANITY.  5 1 

rally  ask  first,  with  a  view  to  the  patient's  probable  course :  Has  the 
mental  disorder  attacked  an  intact  brain  or  not?  or,  is  it  a  brain 
whose  conformation  and  nutrition  were  probably  defective?  Then 
we  naturally  search  for  a  cause,  which  may  be  purely  psychic  in  the 
first  instance,  or  which  may  depend  on  disease  of  a  functional  or 
organic  character  in  some  part  of  the  body,  which,  acting  on  the 
brain,  has  produced  either  congestion  or  anaemia  of  that  organ  which 
ministers  to  the  manifestations  of  mind.  Then  we  want  to  know  the 
psychical  state  of  our  patient,  to  ascertain  whether  he  will  be  dan- 
gerous to  himself  and  others.  Has  he  mental  depression  or  melan- 
cholia, mental  exaltation,  or  mania,  or  monomania,  or  has  he  mental 
weakness?  We  are  desirous  to  be  perfectly  informed  about  all  this. 
Then  we  want  to  know  whether  the  intellect  or  the  ideas,  the  feelings 
and  the  moral  sentiments,  or,  finally,  the  propensities,  instincts,  or 
desires  are  principally  affected.  We  see,  therefore,  that  for  clinical 
purposes,  which,  after  all,  are  the  most  important,  we  need  in  a  work- 
ing classification,  a  combination  of  pathological,  psychological,  symp- 
tomatological,  and  setiological  systems  which  it  is  next  to  impossible 
to  attain  in  any  one  system  of  classification,  however  good  it  may  be. 
The  various  authors  of  these  different  classifications  all  deserve  the 
greatest  respect  and  credit  for  their  laborious  exertions  in  behalf  of 
practical  psychiatry.  The  physiologist  will  say  :  "  I  regard  insanity 
as  divisible  from  my  standpoint  according  as  it  arises  from  disease  of 
the  cerebral  heinisplieres  alone,  as  we  see  in  idiocy,  imbecility,  de- 
mentia, etc.,  or  from  diseases  combined  with  disorder  of  the  sensory 
ganglia  or  nerves,  as  exhibited  in  hallucinations  and  illusions,  or  from 
such  defect  or  disorder  combined  with  disturbances  of  the  motor  gan- 
glia, indicated  either  by  their  excessive  action,  as  in  mania,  or  by  their 
depression  and  disorganization,  as  in  general  paralysis,  or  compli- 
cated with  an  affection  of  the  sympathetic  or  vaso-motor  system  and 
marked  by  vascular  disturbance."  From  his  standpoint  he  is  quite 
right.  My  metaphysical  friend  says  :  "  Insanity  affects  the  intellect, 
the  emotions,  or  the  will,  and  I  can  always  put  cases,  according  to 
their  prominent  character,  under  one  or  other  of  these  heads."  Very 
true;  if  you  are  an  experienced  psychiatric  physician,  you  probably 
can. 

The  psychologist  says  :  "  All  insanity  can  be  classified  under  intel- 
lectual and  emotional  heads  and  under  the  psychical  states  of  depres- 
sion, exaltation,  or  mental  weakness."  He  is  quite  correct,  also. 
The  somato-setiological  physician  says :  "  Every  case  of  insanity  has 


52  PSYCHOLOGICAL    MEDICINE. 

its  physical  cause,  and  I  put  every  case  under  its  special  cause." 
Quite  correct,  if  you  can  verify  it.  The  pathologist  says :  "  All 
insanity  can  be  grouped  under  the  heads  of  arrested  or  impaired 
development  of  the  brain — idiophrenic,  sympathetic,  anaemic,  diabetic, 
toxic  and  metastatic,  phrenitic,  enteric,  rheumatic,  and  pellagrous 
insanity."  These  views  are  certainly  sound  from  a  pathological 
standpoint.  Dr.  Schrceder  van  der  Kolk  says :  "  All  insanity  is 
either  idiopathic  or  sympathetic."  He  is  certainly  correct.  All  are 
right,  and  yet  none  of  them,  when  taken  singly  and  alone,  makes  a 
complete  and  exhaustive  classification  of  insanity. 

Dr.  Bucknill  has  a  very  good,  although  complicated,  classification, 
consisting  of  the  combination  of  psychical  characters  or  phenomena 
with  pathogenetic  relations  and  pathological  conditions,  the  first  form- 
ing the  classes ;  the  second,  the  orders  and  genera ;  and  the  third, 
the  species. 

The  classes  of  psychical  phenomena  include  melancholia,  mania, 
and  dementia,  with  sub-classes  of  psychical  combinations  and  trans- 
mutations. 

The  orders  of  pathogenetic  relations  include  simple,  allied,  sequen- 
tial, concurrent,  egressing,  metastatic,  and  climacteric  insanity. 

^\\&  genera  of  pathogenetic  relations  comprises  the  subdivisions  of 
the  orders.  The  species  of  pathological  conditions  differentiating  the 
genera  by  pathological  conditions  of  the  brain  and  nerves,  of  the 
blood  and  the  nutrition,  he  divides  into  neurotic,  haemic,  and  trophic, 
with  appropriate  subdivisions. 


CHAPTER  II. 

ETIOLOGY     OF     INSANITY     AND     THE     IMPORTANCE    OF    ITS    EARLY 
RECOGNITION   AND    REPRESSION    IN    THE    INCIPIENT   STAGE. 

Insanity  grows  out  of  a  violation  of  those  physical,  mental  and 
moral  laws  which,  properly  understood  and  obeyed,  result  not  only  in 
thehighestdevelopmentof  the  race,  but  the  highest  type  of  civilization. 
During  the  past  twenty  years  there  has  been  a  decided  increase  of  insan- 
ity in  our  country,  disproportionate  to  the  increase  of  population. 
The  increase  of  insanity  over  that  of  population  amounts  to  about 


ETIOLOGY   OF   INSANITY.  53 

12  per  cent.  In  the  foreign  element,  this  is  due  to  marked  changes 
in  habits  of  living,  the  changes  in  food,  increased  intemperance, 
working  more  indoors,  living  in  badly  ventilated  tenements,  disap- 
pointment in  not  succeeding  in  business,  etc.,  as  they  had  expected  to 
do  in  America,  all  of  which  causes  combined  tend  to  impair  health, 
break  down  the  nervous  system,  and  tend  insensibly  toward  insanity 
in  the  offspring.  Respecting  increased  intemperance  as  a  cause  of 
insanity,  the  34th  annual  report  of  the  Crichton  Royal  Institution 
shows  a  rapid  increase  in  insanity  from  drink  as  follows  :  1869,  8 
per  cent.;  1870,  16  per  cent.;  1871,  23  per  cent;  1872,  29  per 
cent.;  1873,  35  per  cent.  Dr.  Gilchrist  remarks  that  "doubtless 
a  more  minute  analysis  would  largely  increase  the  proportion  of 
those  in  which  the  excessive  use  of  stimulants,  by  the  patients  them- 
selves or  by  their  parents,  constitutes  an  important  if  not  the  pri- 
mary factor  in  the  production  of  mental  disturbance."  Casper  said 
that  one-third  of  all  patients  in  the  Berlin  pauper  asylum  were  there 
from  drink.  At  the  Bicetre,  M.  Contease  found  one  thousand  cases  of 
alcoholic  insanity  out  of  five  thousand  two  hundred  and  thirty-eight 
cases.  Dr.  Voison,  of  France,  says,  that  during  the  last  eighteen 
years,  cases  of  insanity  from  drink  have  more  than  doubled.  The 
increase  of  insanity  among  our  own  population  is  due  largely  to  a 
change  from  a  vigorous,  well-balanced  organization  to  an  undue  pre- 
dominance of  the  nervous  temperament,  which  is  gradually  taking 
place  in  successive  generations.  The.  educational  pressure  on  the 
young  to  the  neglect  of  physical  exercise.  The  increasing  artificial 
and  unnatural  habits  of  living,  the  great  excitement  and  competition 
in  business,  are  all  tending  to  induce  and  multiply  nervous  diseases, 
many  of  which  must  terminate  in  insanity.  These  causes  and  the 
evils  resulting  from  them,  are  propagated  by  the  laws  of  inheritance 
in  an  aggravated  and  intensified  form.  It  is  an  interesting  fact 
which  I  have  observed  from  an  extended  examination  of  the  reports 
which  have  been  sent  to  me  from  the  various  insane  asylums  through- 
out our  country,  many  of  which  I  have  examined  from  the  com- 
mencement of  such  institutions  up  to  the  present  time, — that  insanity 
is  appearing  at  an  earlier  age  than  formerly.  These  reports  show 
that  in  former  years  the  average  time  at  which  the  greatest  num- 
ber became  insane,  ranged  between  the  age  of  thirty  and  forty,  but 
an  analysis  of  statistics  shows  that  this  average  age  is  now  coming  on 
at  an  earlier  period  of  life,  generally  appearing  between  the  ages  of 
twenty  and  thirty.     This  is  supposed  by  the  highest  authorities  to 


54  PSYCHOLOGICAL    MEDICINE. 

be  owing  to  hereditary  influences,  which  have  gradually  become  in- 
tensified by  violation  of  physical  laws  in  early  life,  want  of  proper 
training  or  too  high  pressure  in  education.  From  these  preliminary 
remarks,  we  proceed  to  the  investigation  of  the  predisposing  and  ex- 
citing causes  of  insanity. 

The  first  and  great  predisposing  cause  is  hereditary  predisposition. 
This  has  been  noticed  from  the  earliest  history  of  the  study  of  in- 
sanity. Esquirol  pbserved  and  traced  hereditary  predisposition  in 
about  one-fourth  of  all  his  cases  of  insanity.  Guislain  estimated  he- 
reditary predisposition  at  30  percent,  of  all  cases  of  insanity.  Michet 
gave  the  opinion  that  at  least  one-half,  if  not  three-fourths,  of  all  the 
insane  have  either  had  at  some  time  past,  or  have  at  the  present  time, 
some  cases  of  insanity  in  their  families.  At  the  York  Asylum  dur- 
ing twenty-seven  years,  from  1846  to  1872,  hereditary  predisposition 
was  traced  in  3 1  per  cent,  of  all  the  admissions.*  With  regard  to  he- 
reditary predisposition,  it  has  been  determined  that,  as  a  general  rule, 
if  the  mother  is  insane,  the  disease  is  more  frequently  transmitted  to 
the  offspring  than  if  the  father  be  affected ;  and  also,  the  mother's 
influence  in  transmitting  insanity  to  girls  is  much  more  to  be 
dreaded  than  if  the  offspring  be  a  boy;  likewise  as  regards  the  father, 
insanity  being  much  more  certain  to  appear  in  male  offspring,  the 
father  being  affected,  than  in  the  female.  There  are,  of  course,  many 
exceptions  to  this  rule;  but  the  laborious  researches  of  Mr.  Bail- 
larger  have  been  accepted  by  the  best  authorities  as  highly  probable, 
if  not  conclusive. t  It  has  also  been  proved  that  the  lower  forms  of 
insanity,  as  imbecility,  and  also  depression  of  mind,  are  in  a  marked 
degree  hereditary.  It  has  been  remarked  that  the  outbreaks  of  in- 
sanity in  persons  who  inherit  a  predisposition  to  it,  generally  make 
their  appearance,  and  seem  to  be  in  some  manner  connected  with 
the  growth  and  process  of  evolution  of  the  individual  at  the  period 
of  puberty,  childbirth,  climacteric  period,  etc.  Most  people  ignore  the 
law  of  progressive  development,  and  find  it  difficult  to  believe  that 
an  attack  of  insanity  coming  on  in  maturity,  may  have  originated  in 
the  parent  or  grandparent,  in  whom  it  gave  very  little,  if  any,  ap- 
preciable trace  of  its  existence.  Yet  this  is  a  fact,  and  is  often  the 
result  of  a  lowered  vitality  or  abnormal  organic  development  of  the 

*  Guy's  "Hospital  Reports"  for  1877  show  that,  at  Bethlem  Hospital,  Dr.  Savage 
has  traced  hereditary  predisposition  in  34.9  per  cent,  of  1072  admissions.  Out  of  901  ad- 
missions to  the  Crichton  Royal  Institution,  Dr.  Stewart  found  447  cases,  or  49.61  per  cent., 
whose  parents  or  collateral  relatives  were  affected. 

f  These  conclusions  were  deduced  from  600  cases  of  hereditary  insanity. 


.ETIOLOGY   OF   INSANITY.  55 

nervous  system,  that  has  descended  from  generation  to  generation, 
gaining  in  intensity  until  it  manifests  itself  by  an  outburst  of  insanity 
in  children.  One  very  important  organic  law  which  should  be  uni- 
versally understood,  is,  that  morbid  impulses  and  characteristics  and 
insane  traits  may  disappear  in  the  second  generation,  and  break  out 
with  renewed  intensity  in  the  third.  It  is  doubtless  true,  however, 
that  a  tendency  or  predisposition  to  mental  disease  may  be  trans- 
mitted to  the  offspring,  and,  under  good  hygienic  and  other  favora- 
ble conditions,  die  out,  and  fail  to  be  transmitted  any  further.  Insan- 
ity also  may  appear  in  the  same  form  in  succeeding  generations,  or 
it  may  assume  an  entirely  different  form  or  even  assume  another 
form  of  nervous  disease.  Thus,  it  is  common  to  see  cases  in  which, 
the  patient  suffering  from  mania,  the  offspring  may  develop  symp- 
toms of  epilepsy  or  chorea.  Some  authors  have  held  that  noth- 
ing was  transmissible  to  the  offspring  but  an  aptitude  or  predisposi- 
tion to  some  disease  of  the  nervous  system,  and  that  the  develop- 
ment of  any  particular  type  or  form  of  nervous  disease  was  largely 
the  result  of  circumstances  subsequent  to  birth.  The  diseases  most 
frequently  presenting  themselves  as  the  result  of  hereditary  predis- 
position, have  been  found  to  be,  aside  from  the  typical  forms  of  in- 
sanity, hypochondriasis,  apoplexy,  paralysis,  epilepsy,  convulsions, 
chorea,  hysteria,  and  neuralgia.  Undoubtedly,  next  to  hereditary 
predisposition,  may  be  marked  in  the  present  day  as  a  predisposing 
cause  of  insanity,  the  great  mental  activity  and  strain  upon  the  nervous 
system  that  appertain  to  the  present  age  and  state  of  civilization.  The 
same  feverish  haste  and  unrest  which  characterize  us  as  a  nation  to-day, 
and  the  want  of  proper  recreation  and  sleep,  tend  to  a  rapid  decay  of  the 
nervous  system,  and,  sooner  or  later,  the  most  overworked  and  over- 
strained minds  stagger  beneath  the  excessive  burden  ;  and,  one  by  one 
brilliant  intellects  and  sterling  men  are  lost  to  the  world,  who,  if  they 
had  exercised  moderation  in  their  respective  pursuits,  might  have 
been  spared  for  years  to  enjoy  the  fruits  of  their  industry.  Among 
other  predisposing  causes  may  be  mentioned  those  included  by  the 
International  Congress  of  1867,  namely,  great  difference  of  age  be- 
tween parents;  influence  of  sex;  of  surroundings ;  convulsions  or 
emotions  of  the  mother  during  gestation  ;  epilepsy  ;  other  nervous 
diseases;  pregnancy;  lactation;  menstrual  period ;  critical  age ;  pu- 
berty ;  intemperance ;  venereal  excess,  and  onanism.  Among  the  ex- 
citing causes  of  insanity  may  be  mentioned,  trouble  and  excessive 
grief;  intemperance ;  excessive  excitement  of  whatever  kind;  epilepsy; 


56  PSYCHOLOGICAL    MEDICIXE. 

disordered  functions  of  menstruation  ;  pregnancy ;  parturition ;  lac- 
tation ;  fevers  ;  injuries  to  the  head  or  spine,  and  overwork.* 

Intemperance. — It  is  impossible  to  estimate  the  complex  influences 
that  intemperance  exerts  in  the  production  of  insanity.  All  obser- 
vers agree  that  it  is  intimately  connected  with,  and  is  one  of  the  main 
exciting  causes  of  insanity.  Lord  Shaftesbury,  in  his  evidence  before 
the  select  committee  on  lunatics  in  1859,  expressed  his  opinion  that 
fifty  per  cent,  of  the  cases  admitted  into  English  asylums  are  due  to 
drink.  Many  superintendents  of  foreign  asylums  have  estimated 
the  admissions  from  intemperance  at  twenty-five  per  cent,  or  higher, 
including  not  only  the  proximate,  but  remote  cause  of  the  disease. 
This  percentage  will  be  largely  increased  if  we  take  into  account  the 
great  number  of  cases  in  which  the  intemperance  of  parents  causes 
the  insanity  or  idiocy  of  their  offspring.  I  have  traced  intemperance 
as  a  cause  in  a  great  many  cases  of  general  paralysis  that  have  come 
under  my  care,  and  other  superintendents  of  insane  asylums  have 
observed  the  same  thing. 

M.  Lunier  estimates  that  fifty  per  cent,  of  all  the  idiots  and  imbe- 
ciles to  be  found  in  the  large  cities  of  Europe  have  had  parents  who 
were  notorious  drunkards.  Of  350  insane  patientsadmitted  during  two 
years  at  Charenton,  in  Europe,  insanity  was  attributed  to  drink  in  102 
instances.  We  have  three  forms  of  insanity  resulting  from  the  abuse 
of  alcohol  either  in  the  individual  himself  or  his  progenitors,  and 
these  should,  I  think,  be  all  included  under  the  general  term  of  al- 
coholic insanity.  As  this  term  is  at  present,  however,  synonymous 
with  chronic  alcoholism,  we  must  find  some  more  fitting  term,  I 
suppose,  to  include  these  three  manifestations.  They  are  as  follows : 
First,  delirium  tremens  or  mania  a potu,  which  is  the  acute  and  tempo- 
rary form  of  mental  derangement  caused  by  intemperance.  Secondly, 
dipsomania,  which  is  characterized  by  an  irresistible   impulse   to   in- 

*  Hereditary  predisposition  in  respect  to  marriage ;  persons  with  an  insane  diathesis 
should  never  marr)- ;  hysteria  is  not  generally  benefited  by  marriage ;  epileptics  should 
not  marry.  We  are  not  in  a  position  to-day  to  say  what  cases  of  insanity  will  or  will  not 
recur  after  marriage.  The  danger  to  neurotic  subjects  is  that  of  insanity,  hysteria,  or 
epilepsy  as  a  result  of  the  marriage.  Marriage  may  or  may  not  be  beneficial  in  hysteria. 
Among  the  great  evils  of  the  day,  which  should  be  stamped  out  mercilessly,  are  fruitful 
marriages  among  those  belonging  to  insane  families.  An  insane  diathesis  may  or  may 
not  be  hereditary.  This  diathesis  is  marked  by  an  excitable,  nervous,  melancholic  tem- 
perament. Respecting  consanguineous  marriages,  experience  shows  the  injurious  influ- 
ence of  such  unions,  for  if  there  is  a  taint  of  insanity  it  will  be  intensified.  It  is  not  the 
fact  of  relationship,  but  the  chance,  of  both  having  "  similar  vitiations  of  constitution." 


ETIOLOGY    OF    INSANITY.  57 

dulge  in  alcoholic  stimulants — an  impulse  which  the  intellect  seems 
powerless  to  control,  being  overborne  by  the  superior  force  derived 
from  disease.  It  becomes,  therefore,  properly  speaking,  a  form  of 
moral  insanity.  Excluding  the  symptoms  of  delirium  tremens, 
which  are  too  familiar  to  bear  repetition,  we  have  in  the  other  two 
forms  of  insanity  from  intemperance,  hallucinations  of  sight  and 
hearing,  confusion  of  thought,  perversion  of  feelings,  suicidal  tenden- 
cies, tremor  of  the  facial  muscles  and  tongue,  at  times  anaesthesia  of 
the  extremities,  with  paralytic  symptoms,  ending  in  general  paralysis. 
It  is  a  fact  of  importance  that  the  children  of  habitually  intemper- 
ate parents  often  inherit  a  predisposition  to  mental  diseases,  which 
generally  appear  in  the  form  of  weakened  mental  faculties,  as  in  de- 
mentia, or  that  they  are  entirely  wanting,  as  in  idiocy.* 

Domestic  troubles  and  griefs  are  a  frequent  cause ;  and  it  is  roughly 
estimated  that  fromtwelveto  fifteen  percent,  of  admissions  are  from  this 
cause.  Under  the  head  of  exciting  causes  are  also  included  physical 
causes,  as  artificial  deformities  of  the  cranium,  organic  disease  of  the 
brain,  etc.  There  are  few  of  our  asylums  where,  in  the  annual  report, 
there  does  not  appear  a  table  setting  forth  the  causes  of  the  mental 
attack.  For  myself,  I  do  not  regard  these  facts  of  the  highest  value 
when  accumulated  year  after  year,  or  that  they  furnish  very  impor- 
tant data.  They  do  not  demonstrate,  to  me  at  least,  the  aetiology 
of  insanity.  In  the  first  place,  these  reports  are  compiled  on  no  com- 
mon plan,  and  therefore  the  statistics  cannot  be  reliable.  For  each  case 
of  insanity,  in  an  asylum  case-book,  a  single  cause  or  two  causes  are 
allotted.  It  is  decidedly  the  exception,  I  think,  to  find  a  single  cause 
producing  insanity  in  any  given  case,  and  we  entirely  lose  sight  of 
the  collateral  causative  influences  of  the  attack  of  the  cerebral  disease, 
which  to  me  is  very  important,  and  is,  I  think,  to  any  thoughtful 
physician.  Instead  of  finding  out  one  cause  which  I  can  say  is  the 
cause  of  a  given  patient's  insanity,  I  prefer  primarily  to  know  whether 
hereditary  tendency  has  contributed  to  the  production  of  the  mental 
disorder,  and  then  to  be  acquainted  with  all  the  influences  which  have 
been  concerned  in  the  production  of  the  mental  disease.  I  think  that, 
in  most  cases  of  mental  disorder,  we  are  apt  to  find  severali-3.ztox°,  which 

*  Dr.  Crichton  Browne,  in  vols.  i.  and  ii.  of  the  "  West  Riding  Lunatic  Asylum  Re- 
ports," says  that  the  fact  of  the  greater  size  of  the  head  in  civilized  races,  ufiaccompanied 
by  a  proportionate  increase  in  the  pelvic  diameters,  is  an  influence  operating,  to  a  great 
extent,  in  the  production  of  idiocy,  imbecility,  and  insanity.  Dr.  Down  says  that  the 
greater  difficulty  of  parturition  and  the  exalted  emotional  life  of  the  mother  is  the  main 
cause  of  the  danger  to  mental  power  in  the  eldest  child.     We  think  him  right. 


58  PSYCHOLOGICAL   MEDICINE. 

we  cannot  separate  properly,  and  that  rt//have  played  a  part  in  inducing 
cerebral  disease.  Statistics,  therefore,  of  the  causes  of  insanity,  are  too 
apt  to  be  inadequate  and  unsatisfactory  to  the  student  of  psychological 
medicine,  and  he  will  gain  more  by  studying  the  detailed  records 
of  individual  cases,  and  extracting  his  facts  from  such  study. 
When  we  see  how  readily  and  inevitably  the  future  mental  state  and 
characteristics  of  the  next  generation  are  determined  by  the  health 
and  the  proper  mode  of  living  of  the  present  one,  it  behooves  all 
physicians,  who,  perhaps  more  than  any  class  of  men,  are  placed  in 
the  closest  and  most  confidential  relations  to  their  fellow-men,  to  en- 
deavor to  promote  such  modes  of  living  and  thinking,  that  the  de- 
scendants of  the  present  generation  may  be  the  gainers  and  not  the 
losers  by  their  advice.  The  very  mental  states  and  emotions  of  a 
pregnant  woman  are  indelibly  impressed  upon  the  offspring,  and 
how  important  it  is  that  the  condition  of  such  a  woman  should  be  that 
expressed  by  the  old  motto  mens  sana  in  corpore  sano  ! 

Herbert  Spencer,  in  speaking  of  the  emotions,  remarks,  "  We  know 
that  emotional  characteristics,  in  common  with  all  others,  are  heredi- 
tary, and  the  differences  between  civilized  nations,  descended  from  the 
common  stock,  show  us  the  cumulative  results  of  small  modifications 
hereditarily  transmitted.  And,  when  we  see  that  between  savage  and 
civilized  races,  which  diverged  from  each  other  in  the  remote  past, 
and  have  for  a  hundred  generations  followed  modes  of  life  becoming 
even  more  unlike,  there  exist  still  greater  emotional  contrasts,  may  we 
not  infer  that  the  more  or  less  distinct  emotions  which  characterize 
civilized  races  are  the  organized  results  of  certain  daily  repeated 
combinations  of  mental  states  which  social  life  involves?  Must  we 
not  say  that  habits  not  only  modify  emotions  in  the  individual,  and 
not  only  beget  tendencies  to  like  habits  and  accompanying  emo- 
tions in  descendants,  but  that,  when  the  condition  of  the  race 
makes  the  habits  persistent,  this  progressive  modification  may  go  on 
to  the  extent  of  producing'emotions  so  far  distinct  as  to  become  new; 
and  if  so,  we  may  suspect  that  such  new  emotions,  and  by  im- 
plication all  emotions,  analytically  considered,  consist  of  aggregated 
and  consolidated  groups  of  these  simpler  feelings,  which  habitually 
occur  together  in  experience  ;  that  they  result  from  combined  experi- 
ences and  are  constituted  of  them."  Respecting  the  cause  of  insan- 
ity among  Americans  to-day,  I  do  not  hesitate  to  say,  that  inherit- 
ing a  delicate  nervous  organization,  far  in  excess  of  physique,  as  a 
rule,  gives  rise  in  modern  society  to  a  great  increase  of  the  neuro- 


ETIOLOGY   OF    INSANITY.  59 

pathic  constitution.  I  have  found  overstrain  of  the  brain  and  ex- 
cessive use  of  stimulants  to  be  two  of  the  principal  causes  of  insanity, 
and  also  of  diseases  of  the  nervous  system  generally.  For  a  moral 
cause  to  produce  insanity  seems  to  me  to  necessitate  an  organic 
predisposition  to  it,  although  no  doubt  sometimes  a  nutritive  distur- 
bance of  the  brain  may  be  produced  by  shock  to  the  nervous  sys- 
tem, which  may  result  in  mental  disorder  in  a  previously  healthy  per- 
son.    This,  I  think,  however,  is  a  rare  occurrence.* 

The  Importance  of  the  Early  Recognition  and  the  Repres- 
sion OF  Mental  Disease  in  its  Incipient  Stages. 

There  exists  in  insanity,  in  common  with  other  cerebral  diseases, 
a  stage  of  incubation,  in  which  the  insanity  is  not  yet  characterized, 
and  in  which  it  commences  with  incomplete  manifestations.  It  is  an 
equivocal  state,  differing  but  little  from  perfect  sanity,  but  it  is  the 
earliest  phase  of  mental  alienation,  and  if  recognized  by  the  general 
practitioner,  and  promptly  treated  in  this  incipient  stage,  subsequent 
trouble  might  be  averted.  As  a  primary  proposition  for  the  consid- 
eration of  the  general  practitioner,  who  must,  for  the  prevention  of 
insanity,  understand  the  principles  which  are  the  foundation  of  psy- 
chological medicine,  we  would  say,  that  in  his  relations  with  the 
young  in  the  educational  period,  he  should  remember  that  precocity 
is  a  sign  of  biological  inferiority,  and  that  the  precocity  of  organisms 
and  organs,  is  in  an  inverse  ratio  to  the  extent  of  their  evolution. 
The  psycho-neuroses  which  attack  an  intact  brain,  often  commence 
in  intellectual  exertion  of  the  exhausted  brain,  the  exhaustion  being 

*  Respecting  the  relations  of  the  seasons  to  mental  disturbance,  Parchappe,  Guislain, 
Aubanel,  and  Thore  all  agree  that  there  is  a  greater  frequency  of  attacks  of  insanity  during 
the  summer  months,  while  periodical  insanity  appears  in  the  spring.  As  to  the  influence 
of  civilization  as  a  cause  of  insanity,  Drs.  Bucknill  and  Tuke  say  that  insanity  attains  its 
maximum  developm  ent  among  civilized  nations,  remai  ning  at  a  minimum  among  barbarous 
nations,  the  unfavorable  causes  being  principally,  the  increased  susceptibility  of  the  emo- 
tions to  slight  impressions;  the  abuse  of  stimulants ;  the  overwork  of  the  brain,  especially 
in  early  life,  by  an  overwrought  system  of  education  ;  and  that  condition  of  the  lower 
classes  which  is  a  constant  attendant  upon  civilization — the  higher  emotions  or  moral  sen- 
timents, the  lower  propensities  and  the  intellectual  faculties,  being  thus  all  subjected, 
separately  or  combined,  to  an  amount  of  excitement  unknown  to  savage  tribes.  From  all 
the  preceding  it  does  not  necessarily  follow  that  civilization  carried  to  its  perfect  develop- 
ment, a  civilization  that  would  exactly  temper  the  force  of  the  emotions,  moderate  intellec- 
tual exertion,  and  banish  intemperance,  would  generate  mental  disease.  We  must 
educate  the  lower  classes  and  moderate  the  intellectual  strain  on  the  higher  classes,  to 
antagonize  insanity  and  prevent  it. 


6o  PSYCHOLOGICAL   MEDICINE. 

induced  by  taking  up  too  great  a  variety  of  subjects  for  study  during 
the  educational  period  of  life.  We  have,  as  a  result,  a  passive  dilata- 
tion of  the  bloodvessels  of  the  brain,  connected  with  disturbances  of 
nutrition,  and  anaemia  of  the  brain  which  may  produce  grave  nutri- 
tional disturbances  in  the  ganglion  cells  of  the  cortex  of  the  brain. 
We  get,  as  a  result  of  either  of  these  states,  habitual  headache  and  a 
loss  of  intellectual  tone.  Perhaps  these  slight  disturbances  may  not 
attract  particular  attention,  or  such  cases  may  be  dismissed  with 
some  simple  prescription,  but  we  must  remember  that  one  of  the 
gravest  and  most  incurable  of  nervous  disorders,  progressive  paral- 
ysis, commences  in  just  this  insidious  manner,  as  a  vaso-motor  dis- 
turbance of  nutrition  of  the  cortical  portion  of  the  brain,  where  the 
vessels  of  the  pia  mater  soon  get  into  a  state  of  passive  dilatation, 
and  the  disease  thus  established  proceeds  to  its  termination.  Great 
attention  should,  therefore,  be  paid  to  the  very  earliest  indications  of 
brain  exhaustion,  whether  in  school  children,  or  the  young  during 
the  whole  educational  period  of  life,  or  in  those  of  more  advanced 
age  where  the  earliest  symptoms  are  those  of  nervous  exhaustion, 
which,  if  not  checked,  rapidly  lapses  into  actual  mental  disorder. 
The  brain  may  not  be  intact,  but  may  be  predisposed  to  the  acquisi- 
tion of  mental  disease  by  hereditary  or  acquired  vices  of  conforma- 
tion or  nutrition,  and  then  constitutional  affective  insanity,  moral  in- 
sanity, the  monomanias,  epileptic  insanity,  hysterical  insanity,  hypo- 
chondriacal insanity,  or  periodical  insanity  may  result,  if  nervous 
exhaustion  should  appear  and  run  an  unchecked  course,  or  if  the 
early  symptoms  of  these  states  be  disregarded  as  matters  of  slight 
importance.  If  a  patient  complains  of  general  malaise,  impaired 
nutrition  and  assimilation ;  if  we  find  muscular  atonicity  changing 
the  facial  expression;  if  neuralgia  is  present;  if  we  find  cerebral 
anaemia;  if  we  find  our  patient  manifests  mental  depression,  and 
above  all  if  he  is  sleepless,  we  have,  indeed,  a  rapid  state  of  nervous 
prostration  which  may  soon  precipitate  the  patient  into  active  insanity, 
if  these  symptoms  are  not  most  effectively  combated.  Irritability 
and  distrust  are  grave  psychical  symptoms  in  asthenic  cases.  If  we 
have  cerebral  hyperaemia  in  our  patient,  headache  may  then  be  a 
prominent  symptom.  We  must  recognize  these  symptoms  as  those 
of  a  grave  nervous  prostration,  which  unchecked  lapses  into  actual 
insanity  with  great  readiness.  I  never  like  to  see  neuralgia  develop- 
ing in  such  cases,  as  it  is,  when  not  malarial,  very  often  a  premoni- 
tory  symptom   of  impending   mental   disturbance,  when   associated 


ETIOLOGY   OF    INSANITY.  6 1 

with  other  symptoms  of  nervous  prostration.  Profuse  perspirations 
also  are  found  in  connection  with  nervous  prostration,  and  occur  at 
any  hour  of  the  day  or  night.  A  loss  of  the  normal  elasticity  of  the 
skin  is  another  prominent  symptom  of  disorded  nervous  action. 
Arsenic  as  a  remedy  in  this  latter  class  of  cases  is  very  valuable.  In 
children,  or  young  people  from  fifteen  to  twenty  years  old,  very  grave 
psychical  disorders  may  appear,  which  require  the  promptest  treat- 
ment. The  history  of  such  patients  will  usually  be,  that  during 
childhood  they  have  been  excessively  nervous,  and  have,  perhaps^ 
had  convulsions  in  infancy.  They  have  been  very  emotional  chil- 
dren, suffering  from  night  terrors.  There  are  periods  of  marked 
mental  inactivity,  alternating  with  a  hyper-activity  of  the  mental 
functions,  and  such  patients  do  not  take  or  manifest  a  normal  healthy 
interest  in  their  surroundings.  If  hysterical  girls,  they  may  neither 
eat  nor  sleep  for  some  days  at  a  time.  There  are  no  suicidal  or  homi- 
cidal tendencies  in  these  cases,  but  a  disposition  to  recurrent  mania. 
In  the  menstrual  psychoses  of  young  girls  and  women,  the  psychic 
disorders  which  come  on  at  these  times  in  many  of  them,  are,  I 
think,  more  than  a  natural  exaggeration  of  the  nervous  excitability 
which  we  may  naturally  expect  in  a  female  at  this  period.  It  is  a 
true  periodic  insanity  in  many  cases,  an  acute  psychosis,  with  the 
intellectual  centres  involved.  They  are  vaso-motor  neuroses  with 
recurrent  cerebral  h^^peraemia.  We  find  this  form  of  periodical  in- 
sanity at  any  epoch  of  sexual  life,  and  there  is  marked  physical  and 
mental  prostration  in  the  intervals  between  the  paroxysms,  and  we 
should  combat  these  states  by  every  means  in  our  power.  I  remove 
uterine  trouble,  if  any  exist ;  use  the  constant  current  of  electricity 
to  the  central  nervous  system  to  improve  its  nutrition,  and  give 
sodium  bromide  (grains,  6d)  and  fluid  extract  ergot  (5/^),  in  combi- 
nation, thrice  daily.  The  monobromide  of  camphor,  in  Clin's  cap- 
sules of  4  grains  each,  is  also  very  valuable  in  some  of  these  cases, 
given  twice  daily,  the  last  dose  just  before  retiring.  I  also,  for  one 
week  preceding  the  appearance  of  the  menses  in  such  women,  epi- 
ploy  cerebral  electrization  daily,  using  the  constant  current,  which 
possesses  the  power  of  combating  and  perfectly  antagonizing  the 
various  congestive  states,  which,  unchecked,  lead  to  insanity.  Of  all 
the  cases  in  which  I  am  accustomed  to  use  electrization  of  the  brain, 
none  give  more  gratifying  results  than  these  periodic  menstrual 
psychoses  in  women.  A  marked  tendency  to  sleep,  even  in  cases 
which  have  been  sleepless  for  days,  follows  these  applications.     I 


62  PSYCHOLOGICAL    JIEDICIXE. 

have  never  seen  any  evil  results  from  the  use  of  moderately  strong 
currents  judiciously  applied;  on  the  contrary,  I  have  more  than 
once  prevented  the  access  of  insanity  by  this  means.*  Certainly,  I 
know  that  in  many  cases  where  there  had  been  a  recurrent  menstrual 
psychosis,  or  mania,  this  treatment  has  resulted  in  my  hands  in  the 
complete  cure  of  the  patient,  when  conjoined  with  the  proper  medici- 
nal treatment,  so  that  I  most  earnestly,  and  from  experience,  advo- 
cate its  use.  I  shall,  in  a  subsequent  chapter  in  this  volume,  give 
my  views  at  length  on  the  subject  of  the  value  of  the  constant  or 
galvanic  current  of  electricity  as  an  application  to  antagonize  the 
various  congestive  states  of  the  brain. 

I  would  insist  upon  the  point,  that  in  young  ladies,  especially,  the 
mental  future  depends  very  largely  upon  the  nervous  and  physical 
strength  which  they  attain  before  the  age  of  twenty-one.  Many  patients 
are  brought  to  me  suffering  from  nervous  prostration  and  protracted 
headaches,  during  the  monthly  menstrual  epoch,  all  on  account  of  too 
great  intellectual  exertion,  inducing  a  very  nervous  and  hysterical  con- 
dition. These  are  the  young  ladies  who  stand  high  in  their  classes  at 
schools  and  seminaries.  We  too  often  sacrifice  the  constitution  to  what 
we  deem  educational  Jiecessitics.  I  deem  the  necessity  in  a  young  girl, 
to  have  plenty  of  bone,  blood,  and  muscle,  and  to  be  well  developed, 
with  an  accurate  balance  between  the  physique  and  the  nervous  system, 
and  if  something  has  to  be  sacrificed,  let  it  be  some  of  her  educa- 
tion, and  not  some  of  her  mental  or  physical  health.  Insanity  will 
just  as  surely  follow  neglect  of  mental  hygiene,  as  the  zymotic  dis- 
eases follow  neglect  of  sanitary  precautions ;  and  we  too  often  forget 
this  fact,  for  the  reason  that  the  incubating  stage  of  insanit)'-  may  be, 
and  often  is,  long  and  insidious,  and  easily  overlooked  by  one  who 
is  not  a  student  of  psychological  medicine.  It  is  very  easy  to  ruin 
the  delicate  tissue  of  the  brain  by  overstraining  it  when  exhausted. 

*  The  writer  has  at  present  under  his  care  a  case  illustrating  the  power  of  the  galvani- 
zation of  the  brain  in -a  young  married  lady,  who  from  neurasthenia  passed  into  a  state  of 
mental  disturbance,  and  thought  it  her  duty — so  she  said — to  murder  her  husband  and  chil- 
dren, to  whom  she  is  devotedly  attached.  She  had  not  menstruated  for  several  months,  and 
her  physician  told  her  that  she  was  suffering  from  "  change  of  life."  Her  age  was  thirty- 
six.  A  course  of  hot  baths  with  cold  to  the  head,  centric  galvanization  and  electrization  of 
the  brain  daily,  with  the  citrate  of  iron  and  quinine  and  the  liq.  acid,  phosph.  comp.  re- 
moved the  amenorrhoea,  so  that  at  the  end  of  three  weeks  my  patient  was  menstruating. 
The  cerebral  hypersemia  was  thus  relieved,  the  idea  of  homicide  vanished  like  dew  before 
the  sun,  and  my  patient  is  to-day,  five  weeks  after  the  first  day  of  treatment,  a  perfectly 
sane  woman.  She  was  also  treated  in  her  own  home,  wMch  1  regard  as  the  severest  test 
of  treatment,  as  such  patients  need  a  change  of  scene  and  surroundings. 


ETIOLOGY    OF    INSANITY.  63 

There  are  too  many  young  brains,  not  strong  and  vigorous,  but  un- 
stable and  subject  to  irregular  and  uncertain  action,  which  have  been 
rendered  so  by  an  entirely  false  system  of  education.  There  is  a 
great  deal  of  brain  fatigue  among  professional  and  business  men, 
resulting  from  a  preponderance  of  waste  over  repair,  which  induces 
grave  nervous  prostration.  Such  patients  complain  of  a  loss  of 
physical  and  mental  power,  and  of  an  inability  to  do  what  they  could 
when  well;  and  these  same  patients  exhibit  exaggerated  sensibility, 
being  very  easily  affected  by  trivial  impressions.  Such  patients 
suffer  much  from  vertigo  and  confusion  of  mind,  owing  to  an  im- 
paired nutrition  of  the  brain  and  spinal  cord  and  a  diminution  of 
vascular  tonus.  One  very  important  set  of  symptoms  to  early  recog- 
nize and  combat,  is  that  characteristic  of  cerebral  syphilis.  In 
these  cases  we  have  a  deepseated  headache,  of  extraordinary  inten- 
sity, with  nocturnal  exacerbations  and  of  long  duration.  The  head- 
ache is  the  premonitory  symptom  of  very  grave  cerebral  mischief, 
which  we  may  ward  off  if  we  recognize  its  significance.  As  the  re- 
sults of  the  cerebral  congestion  of  specific  origin,  we  have  vertigo 
and  mental  dulness,  temporary  disorders  of  the  special  senses,  and 
momentary  impairment  of  the  intellect.  These  symptoms,  at  first 
transitory,  may  become  permanent  by  inattention.  Congestive 
attacks  of  greater  intensity,  even  attaining  the  grade  of  apoplectic 
fits,  may  now  occur,  and  attacks  of  intermittent  paralysis.  In  the 
gravest  forms  of  specific  cerebral  disease,  an  apoplectiform  seizure, 
followed  by  fatal  coma,  may  usher  in  the  attack  with  no  premonitory 
symptoms.  Epilepsy,  if  commencing  aftej'  tzventy  years  of  age,  is  due, 
probably,  to  specific  brain  disease,  and  is  often  preceded  by  the  pre- 
monitory headache  of  which  I  have  spoken.  In  these  cases  I  always 
put  a  patient  immediately  on  energetic  antisyphilitic  treatment,  as  I 
care  little  about  the  history.  The  epilepsy  is  to  me  evidence  of  the 
existence  of  the  disease.  The  mental  symptoms,  when  insanity 
appears,  are  those  of  exaltation,  delirium,  and  mania.  The  gravest 
forms  of  this  disorder  often  yield  rapidly  to  appropriate  treatment.  If 
we  find  in  a  patient,  a  male  more  particularly,  persistent  mental  dulness, 
and  muscular  feebleness,  existing  as  vague  undefined  symptoms,  it  is 
always  well  to  examine  his  history  pretty  thoroughly,  and  a  specific 
course  of  treatment  may  very  likely  prevent,  in  such  a  patient,  the 
invasion  of  insanity.  We  must  not  promise  perfect  recoveries  in 
these  cases  of  cerebral  syphilis,  for  some  never  recover,  and  there 
may  be  incomplete  recoveries.     In   a  certain  proportion  of  cases, 


64  PSYCHOLOGICAL    MEDICLXE. 

however,  we  make  a  rapid  and  brilliant  cure.  Cold  douches  are 
very  valuable  in  cerebral  s}-philis  as  an  adjuvant  to  specific  treatment, 
and  should  never  be  omitted.  I  am  more  inclined  to  think  that 
syphilitic  brain  disease  is  overlooked,  than  that  it  is  so  very  rare  as 
some  authors  claim.  I  have  detailed  the  symptoms  of  the  gradual 
breaking  down  of  the  nervous  system,  causing  nervous  prostration 
and  incipient  insanity,  and  would  now  briefly  state  my  treatment  of 
such  states.  The  treatment  of  insanity  in  general  will  occupy  a 
separate  chapter  in  the  course  of  this  volume. 

We  must  secure  for  our  patient  good  refreshing  sleep,  and  take 
him  away  for  a  time  from  business  cares  and  anxieties,  and,  if  a 
woman,  give  her  rest.  If  the  condition  is  asthenic,  alcoholic  stimu- 
lants are  indicated,  to  ward  off  the  cerebral  anaemia,  which,  if  not 
relieved,  will  bring  on  an  attack  of  mania.  Strychnia  is  also  indi- 
cated in  these  anaemic  states.  I  usually  use  the  citrate  of  iron,  qui- 
nine and  strychnia,  rest,  massage  and  electricity,  together  with  a  milk 
punch  three  times  a  day.  If  there  is  cerebral  congestion,  I  employ, 
as  I  have  said,  the  constant  current  of  electricity  to  the  brain,  to 
antagonize  the  congestive  states.  The  bromide  of  zinc,  commencing 
with  y^  to  I  grain  doses,  and  the  hydrobromate  of  quinine,  are  both 
useful  in  cerebral  congestion,  also  Fothergill's  solution  of  hydro- 
bromic  acid  in  15  to  30  minim  doses.  We  are  more  apt  to  have  an 
anaemic  and  asthenic  condition  of  the  system,  especially  in  women. 
In  these  conditions  quinine  is  one  of  the  best  nerve  tonics,  and  may 
be  given  in  i  or  2  grain  doses  before  each  meal.  Arsenic  in  Fowler's 
solution,  5  minims  after  each  meal,  continued  for  some  weeks  or 
months,  is  also  very  valuable  indeed.  By  appropriate  and  judicious 
treatment  we  may  get  a  perfect  cure  in  the  incipient  stages  of  insanity, 
and  generally  with  no  fear  of  a  relapse,  unless  it  is  strongly  hereditary. 


CHAPTER  III. 

PREVE^;TION    OF    INSANITY. 

Insanity  is  often  a  preventable  malady.  Primarily  we  must  not 
exhaust  the  brains  of  children  by  a  cramming  process  in  education, 
which  cannot  fail  to  injure  the  nutrition  of  the  brain  and  impair  it. 
An  immense  harm  is  done  in  this  way  by  producing  premature  men- 
tal decay  and  nervous  exhaustion,  appearing  about  the  age  of  puberty. 


PREVENTION    OF    INSANITY.  65 

The  body  must  be  developed  in  all  its  parts  and  organs  if  we  want 
healthy  minds.  At  present  we  are  developing  a  race  of  children 
whose  nervous  system  is  far  in  excess  of  their  physique,  who  are 
predisposed  to  the  acquisition  of  nearly  all  the  various  forms  of  ner- 
vous disease  upon  slight  exciting  causes,  and  many  of  these  types 
of  nervous  disease  readily  lapse  into  insanity.  See  to  it,  you  who 
are  family  physicians,  that  the  children  who  grow  up  under  your  care 
are  developed  physically,  even  if  it  be  at  the  expense  of  the  neglect 
of  early  education.  It  is  not  the  precocious  child  who  makes  the 
strong  man  mentally.  Discourage  all  precocity,  and  keep  such  chil- 
dren from  study  until  they  have  a  sound  healthy  body  for  a  founda- 
tion, and  then  avoid  overstimulating  the  mind  by  too  many  studies 
at  once.*  A  young  girl  recently  came  under  my  care  for  complete 
nervous  exhaustion,  who  was  trying  to  master  thirteen  different 
branches  at  once,  in  her  most  trying  period  of  bodily  development. 
A  system  of  education  which  allows  such  nonsense  cannot  be  too 
severely  condemned  by  physicians.  It  is  absurd  for  young  girls  to 
be  put  through  a  cramming  process  of  education,  which,  at  the 
critical  period  of  life,  cannot  fail  to  weaken  their  nervous  system ; 
and,  when  this  is  combined  with  a  society  life,  the  result  is  a  super- 
ficial education,  a  broken-down  nervous  system,  and  an  inability  as 
women  to  go  through  the  trying  duties  of  maternity.  It  is  for  the 
family  physician  to  say  which  children  shall  study  hard,  and  which 
shall  not.  Teachers  of  the  young  are  not  qualified  to  give  any  such 
advice.  The  prevention  of  such  disease  should  be  the  highest  aim 
of  the  physician.  Too  often  an  indifference  is  displayed  by  him 
respecting  his  duties,  as  a  farnily  adviser,  in  such  matters.  Insanity 
is  also  to  be  prevented  by  such  an  education  of  the  masses,  as  will 
make  them  understand  sanitary  and  hygienic  laws,  and  live  in  accord- 

*  The  general  pi'actitioner,  for  whom  this  book  is  especially  intended,  is  in  a  position  to 
check  the  sources  of  insanity  at  their  very  beginnings.  By  carefully  directing  the  mental 
and  physical  life  of  the  pregnant  woman  he  may  form  the  future  mental  complexion  of 
the  unborn  child.  He  may  watch  over  the  child's  brain  during  the  early  formative  period 
of  infancy  and  childhood,  and  so  advise  the  parents  that  they  may  guide  their  children 
in  the  paths  which  lead  to  mental  stability.  He  may  recognize  the  insane  diathesis,  and 
by  intelligently  recognizing  that  a  person  is  more  liable  than  others  to  mental  disease 
may  apply  "  a  wise  culture  to  the  erring  emotions,  and  discipline  to  the  conduct  in  the 
early  years  of  life  while  they  are  yet  applicable,  and  the  fearful  heritage  may  oftentimes 
be  avoided."  Moral  treatment  here  is  the  prevention  of  insanity.  It  has  been  well  said 
that  "  the  celibacy  of  the  insane  is  the  prophylaxis  of  insanity  in  the  race."  Treatment  at 
the  outbreak,  away  from  home  and  under  nurses  who  have  patience,  endurance,  temper 
and  health,  would  often  prevent  lifelong  insanity. 

5 


66  PSYCHOLOGICAL    MEDICINE. 

ance  with  them,  so  that  they  may  develop  the  highest  moral,  physical, 
and  intellectual  health. 

Respecting  men,  I  think  that  modern  nervousness  is  lai-gely  due 
to  mental  anxiety  about  business,  the  abuse  of  tobacco,  and  sexual 
excess.  These  three  things  in  combination,  especially  if  the  use  of 
stimulants  be  indulged  in,  will  break  down  and  shatter  the  strongest 
constitution,  and  induce  ataxy,  paresis,  and  insanity  in  those  who 
inherit  weak  nervous  systems  from  their  progenitors.  Regular 
hours,  amusements  to  divert  the  mind  from  the  cares  of  business, 
freedom  from  alcoholic  stimulants,  nourishing  food  at  regular  hours, 
properly  digested,  abstinence  from  tobacco  during  the  years  previous 
to  puberty  and  until  twenty  years  of  age,  and  daily  attention  to  the 
bowels,  with  free  bathing,  will  keep  most  men  sound  and  healthy. 
The  subject  of  education  in  its  relations  to  mental  disease  is  a  very 
interesting  one.  It  is  very  important,  as  the  elaboration  of  cerebral 
structure  is  taking  place  in  childhood  and  youth,  that  suitable  exer- 
cise and  stimulation  should  be  carefully  applied,  so  that  the  brain 
may  be  brought  to  its  highest  possible  development.  While  we 
must  remember  that  brain-centres  that  are  not  properly  stimulated 
and  exercised  do  not  develop,  and  must  consequently  insist  on  proper 
physical  and  mental  education,  and  moral  and  religious  training,  we 
must,  on  the  other  hand,  as  carefully  avoid  undue  educational  pres- 
sure and  brain-fatigue  and  exhaustion  by  overstimulation,  especially 
in  badly  nourished  or  sickly  children,  or  in  those  who  are  precocious 
and  excitable,  as  too  many  American  children  are. 

It  must  be  carefully  borne  in  mind  that  injudicious  stimulation  of 
the  brain  in  the  teaching  of  children,  may  not  only  induce  nervous- 
ness but  even  structural  disease  itself.  While  I  believe  most  firmly 
in  the  advantages  accruing  from  stimulation  of  the  nervous  centres 
by  education  wisely  applied,  in  those  who  are  strong  and  vigorous, 
and  consider  that  ignorance  produces  a  poor  development  of  imper- 
fectly acting  brain-tissue  which  tends  to  degenerate,  I  deprecate  the 
present  cramming  process  so  common,  which  too  often  menaces  the 
mental  integrity  of  naturally  delicate  children,  who,  in  a  great  many 
cases,  have  inherited  a  disproportionate  development  of  the  nervous 
system  at  the  expense  of  their  physique. 


I 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  6/ 


CHAPTER  IV. 

DIAGNOSIS    OF    INSANITY. 

There  is  probably  no  disease  which  presents  greater  difficulties  in 
the  way  of  diagnosis,  than  insanity.  In  most  diseases  we  examine 
physical  signs  and  symptoms,  and  we  determine  by  our  senses  the 
existence  of  such  diseases.  In  insanity,  on  the  contrary,  we  have  to 
be  guided  chiefly  by  our  knowledge  of  the  normal  functions  of  the 
mind,  and  in  our  examination  we  have  to  rely  on  our  intellect  rather 
than  on  our  senses,  although  of  course  the  latter  are  called  in  to 
assist  us.  It  is,  however,  very  often  extremely  difficult  to  decide 
with  certainty,  as  we  are  expected  to  do,  as  to  the  existence  of  mental 
disease,  and  we  assume  a  great  responsibility,  whichever  way  our 
decision  may  be  given.  We  either  give  the  patient  liberty  to  take 
his  place  in  society,  and  thus  expose  society  to  the  consequences  if 
he  prove  to  be  insane,  or  we  place  him  in  confinement  in  some  insti- 
tution for  the  treatment  of  the  insane,  thus  depriving  him  of  his  lib- 
erty and  his  family  of  his  support. 

It  becomes  then  a  matter  of  great  importance  to  decide  rightly  as 
to  the  existence  of  mental  disease,  for  if  this  is  not  rightly  done,  we 
shall  expose  ourselves  to  the  risk  of  great  mortification,  and  also  to 
the  loss  of  professional  reputation.  Before  going  to  see  a  patient 
who  is  to  be  examined  for  the  existence  of  insanity,  it  is  advisable 
to  find  out  all  one  can  from  the  friends  and  relatives ;  but  in  accept- 
ing such  statements  it  is  wise  to  allow  a  wide  margin  for  their  infor- 
mation in  regard  to  hereditary  predisposition,  as  most  people,  fool- 
ishly considering  the  existence  of  insanity  in  their  family  a  disgrace, 
will  pertinaciously  conceal  and  deny  this  fact.  Another  reason  for  this 
concealment  may  be,  that  the  members  of  such  families  are  not  infre- 
quently odd  and  eccentric  in  their  behavior  even  when  perfectly  sane, 
and  do  not  care  to  have  their  peculiarities  attributed  to  hereditary  taint 
of  insanity,  and  therefore  endeavor  to  mislead  their  physician  on  a  point 
which  is  to  him  of  the  utmost  diagnostic  importance.  Indeed,  this 
and  the  question  of  previous  attacks,  are  perhaps  the  two  most  im- 
portant points  in  the  diagnosis  of  any  given  case.  We  should  en- 
deavor when  we  are  called  to  our  patient,  to  gain  his  confidence,  and 
from  a  general  conversation  lead  him  cautiously  to  his  state  of  health 
and  mental  feeling.     If  we  are  abrupt  and  wanting  in  tact  we  shall 


6S  PSYCHOLOGICAL    MEDICINE. 

probably  defeat  our  object,  and  the  patient,  if  displeased,  will  either 
refuse  to  listen  to  or  answer  our  questions,  or  will  become  very  angry 
at  our  conspiring  to  deprive  him  of  his  liberty.  If  we  are  fortunate 
enough  to  get  a  history  of  the  patient,  we  can  generally  determine 
easily,  the  existence  or  non-existence  of  insanity,  by  the  patient's 
appearance  and  conversation.  Many  times,  however,  we  have  to  rely 
alone  on  the  conversation,  general  appearance,  and  conduct  of  the- 
patient,  unaided  by  any  other  resources.  After  having  gained  our 
patient's  confidence  and  having  drawn  him  into  a  pleasant  conversa- 
tion, we  should  first  inquire  about  previous  attacks,  then  into  his 
hereditary  history,  then  into  any  predisposing  causes,  such  as  intem- 
perance, vocation,  habits,  etc.,  which  may  have  operated  in  the  pro- 
duction of  insanity.  Also  as  to  injuries  to  the  head  or  spine  which 
may  have  occurred,  sunstroke,  etc.  We  should  then  systematically, 
but  carefully  and  cautiously,  examine  into  the  vegetative  and  repro- 
ductive functions,  and  then  carefully  examine  the  nervous  system  for 
the  existence  of  such  lesions  as  paralysis,  epilepsy,  catalepsy,  hysteria, 
and  allied  affections.  We  should  next  examine  the  different  senses, 
beginning  with  sight,  and  in  this  way  we  shall  find  out  if  our  patient 
has  good  vision,  if  the  retina  is  normal,  and,  what  is  more  important, 
we  may  discover  if  he  has  hallucinations  or  illusions  pertaining  to 
this  sense.  We  may  then  proceed  to  the  sense  of  hearing,  examin- 
ing for  deafness,  and  also  to  discover  any  hallucinations  or  illusions 
of  hearing.  Proceeding  to  the  sense  of  smell,  we  shall  discover  if  it 
is  normal,  and  also  if  there  are  any  hallucinations  or  illusions  con- 
nected with  it.  Taking  up  the  sense  of  taste,  we  may  inquire  as  to 
the  existence  of  hallucinations  or  illusions.  Patients  often  complain 
of  their  food  being  poisoned,  or  that  they  are  eating  injurious  and 
hurtful  things  with  their  food.  The  last  of  the  senses,  that  of  touch 
and  nervous  sensibility,  may  be  examined  for  imaginary  sense  of  pain, 
the  existence  of  reflex  action,  hypersesthesia,  and  lastly,  for  halluci- 
nations and  illusions  pertaining  to  this  sense  or  referring  to  internal 
organs  of  the  body.  The  mental  symptoms  unconnected  with  the 
special  senses  and  pertaining  to  the  intellect,  the  emotions,  or  the 
will,  may  finish  the  examination.  Whether  the  diagnosis  of  insanity 
present  itself  to  the  physician  in  a  purely  medical  or  in  a  medico- 
legal point  of  view,  the  principles  of  diagnosis  are  the  same,  and  we 
must  pursue  our  examination  in  precisely  the  same  manner.  The 
first  thing  we  are  generally  called  upon  to  decide  is,  whether  the 
patient  can  be  treated  at  home,  or  whether  it  is  necessary  to  place 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  69 

him  in  an  asylum,  and  we  are  also  probably  asked  for  a  prognosis, 
which  latter  cannot  be  too  guarded,  whatever  may  be  our  own  im- 
pression at  the  time,  about  the  patient.  Let  us  consider  for  a  moment 
the  first  question,  that  of  the  propriety  of  removing  our  patient  from 
his  own  home,  either  to  some  private  retreat  or  to  a  public  asylum. 
For  those  who  can  afford  the  expense  I  prefer  a  residence  away  from 
home  in  some  private  retreat  where  but  few  patients  are  admitted,  for 
the  reason  that  they  unquestionably  can  have  much  greater  care  and 
attention  bestowed  upon  them  than  in  the  congregate  plan  of  treat- 
ment. If  they  cannot  afford  this,  a  residence  in  any  well-regulated 
public  asylum,  where,  as  a  rule,  the  superintendents  are  earnest, 
thoughtful  men,  careful  for  their  patients'  welfare,  is  to  be  desired  as 
soon  as  possible,  while  the  disease  is  in  its  early  curable  stages.*  In- 
sane patients  are,  by  the  very  nature  of  the  disease,  inclined  to  do 
mischief  They  are  controlled  in  their  actions  by  delusions  which 
are  to  them  vivid  realities,  and  no  one  knows  what  they  may  con- 
sider "it  right  and  proper  to  do  when  under  the  influence  of  such 
delusions.  Some  of  the  most  fearful  crimes  have  been  committed 
by  those  who  have  previously  been  regarded  as  harmless  patients, 
and  no  one,  therefore,  should  take  upon  himself  the  responsibility  of 
advisingthatapatient  whomhe  is  called  to  see  should  be  kept  at  home. 
The  mere  moral  effect  of  a  residence  in  a  well-regulated  asylum  for  a 
time,  at  the  onset  of  insanity,  has  an  immense  effect  on  the  mind  of  a 
patient,  and  may  prevent  consequences  that  might  prove  most  disas- 
trous were  he  to  be  at  home  and  exposed  to  the  many  causes  of  excite- 
ment from  which  he  is  sheltered  in  an  asylum.  We  must  also  decide 
what  form  of  insanity  the  patient  is  laboring  under,  and  in  a  medico- 
legal case  must  give  our  diagnosis  as  to  the  insanity  of  the  patient  in  its 
relation  to  his  civil  capacity  and  responsibility  for  criminal  actions,  and 
also  as  to  feigned  and  concealed  insanity.  In  the  latter  class  of  cases, 
medico-legal  cases,  it  is  of  the  utmost  importance  for  every  physician 
to  understand  that  a  man  is  not  irresponsible  for  crimes  which  he  com- 
mits, from  the  fact  that  some  of  his  ancestors  have  been  insane.  The 
question  to  be  determined  here  is,  whether  the  hereditary  taint,  by 
being  transmitted  to  the  individual  in  question,  has  influenced  or 

*  It  should  be  borne  in  mind  that  much  of  the  popular  prejudice  against  hospitals  for 
the  insane  springs  from  unfounded  statements  made  by  persons  who  have  been  inmates 
of  such  institutions,  and  who  have  been  discharged  before  they  were  fully  restored  to 
reason.  A  person  who  has  made  a  complete  recovery  generally  entei tains,  not  hostility, 
but  the  liveliest  feelings  of  gratitude,  towards  those  who  have  been  Instrumental  in  the 
restoration  of  reason.  v 


70  PSYCHOLOGICAL    MEDICINE. 

determined  at  all  his  volitions,  impulses,  or  acts.  If,  on  the  one 
hand,  he  has  been  noticed  for  displaying  such  peculiarities  as  usually 
proceed  from  hereditary  taint,  and  if  the  crime  was  apparently  unac- 
companied by  any  adequate  incentive,  doubts  of  his  legal  guilt  are 
then  to  be  carefully  considered.  On  the  other  hand,  if  the  criminal 
act  appears  to  have  been  rationally  performed,  and  with  some  ade- 
quate and  usual  incentive,  and  if  the  individual  has  previously  been 
free  from  mental  infirmities  or  peculiarities  that  might  be  attributed 
to  hereditary  transmission,  then  we  cannot  justly  advance  insanity  as 
a  plea  for  defence  from  the  consequences  of  crime.  Mental  unsound- 
ness, if  unconnected  with  the  testamentary  disposition,  should  not 
destroy  testamentary  capacity.  If  the  will  is  not  affected  by,  or  is 
not  the  product  of  insane  delusion;  if  the  testator  has  not  ignored 
the  claims  of  near  relationship  or  of  natural  affection ;  and  if  his 
mental  faculties  are  so  far  normal  that  he  understands  the  nature  of 
the  act  and  the  consequences  arising  from  it ;  and  if  he  has  a  clear 
idea  as  to  the  amount  of  property  he  is  disposing  of;  and  if  in 
making  the  will  he  has  not  manifested  any  insane  suspicion  or  aver- 
sion, the  will  should  be  regarded  as  valid. 

The  diagnosis  of  insanity  is  at  times  ver}^  easily  made.  Thus,  if 
we  find  our  patient,  from  having  been  previously  moral,  affectionate, 
and  industrious,  has  become  immoral  and  dissolute,  exhibits  aliena- 
tion of  affections  and  neglects  his  business,  all  without  adequate 
cause,  it  is  of  course  easy  to  determine  his  insanity,  although  of 
course  changes  may  take  place  in  the  character  of  individuals  with- 
out any  suspicion  of  insanity  being  excited.  A  great  many  cases, 
however,  are  on  the  border  line  which  separates  sanity  from  insanit}^, 
and  it  often  requires  the  nicest  discrimination  to  determine  whether 
such  a  patient  shall  be  placed  under  treatment  or  not. 

It  now  remains  to  consider  the  diagnosis  of  the  different  forms  of 
insanity  which  we  meet  with.  In  mania  the  physiognomy  is  gener- 
ally distinctiv^e.  The  countenance  is  furrowed,  the  eye  wild  and 
vacant,  and  there  is  generally  a  peculiar  want  of  agreement  in  the 
expression  of  the  features.  The  hair  often  becomes  harsh  and  brist- 
ling, and  the  ears  may  become  shrivelled.  The  actions,  demeanor, 
and  dress  of  an  insane  patient  are  generally  indicative  of  mental 
peculiarities,  and  oftentimes  the  latter  maybe  indicative  of  the  nature 
of  the  patient's  delusions,  or,  if  not,  it  may  display  marked  eccen- 
tricity. 

In  acute  mania,  it  is  generally  easy  to  discern  in  the  countenance 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  7 1 

the  presence  of  some  strong  emotional  characteristics,  such  as  pride, 
hatred,  or  anger.  It  has  been  remarked  that  insanity  anticipates  the 
effects  of  years  and  prematurely  imprints  upon  the  countenance  the 
facial  lines  characteristic  of  habitual  emotions,  while  in  lunatics  of 
advanced  age,  these  are  observable  in  a  greater  degree,  and  are  more 
deeply  marked  than  they  ever  are  in  sane  persons.  In  this  form  of 
insanity — acute  mania — the  bowels  are  generally  constipated,  the 
urine  is  loaded  with  phosphates,  and  the  patient  suffers  from  pro- 
tracted loss  of  sleep,  which  is  diagnostic  of  acute  mania,  and  which 
is  a  symptom  that  cannot  be  feigned  by  an  impostor.  Patients  of 
this  class  pass  several  days  without  sleep,  and  sometimes  weeks  with 
but  a  few  hours  of  sleep  in  the  course  of  the  whole  time.  Halluci- 
nations of  sight  and  hearing  are  far  more  frequent  in  this  than  in  any 
other  form  of  insanity.  There  may  be  also  rapidly  changing  delu- 
sions, and  there  is  generally  an  intense  muscular  restlessness,  which 
manifests  itself  either  in  destructive  impulses,  or  in  continual  motion, 
which  rapidly  induces  dangerous  exhaustion,  if  not  properly  treated. 

In  melancholia,  the  most  noticeable  symptoms  will  be  despondency, 
fear,  and  despair,  and  the  expression  of  the  mental  states  are  de- 
picted in  an  unnatural  degree  of  intensity  upon  the  countenance  of 
the  patient.  The  patient  generally  wishes  to  be  alone,  is  gloomy  and 
depressed,  has  delusions  of  fear  and  persecution,  imagines  he  has 
committed  unpardonable  sins,  and  in  the  acute  cases  of  melancholia 
no  more  pitiable  spectacle  can  be  imagined,  and  the  expression  of 
terrible  apprehension  and  fear  which  occupies  the  countenance  is  not 
easily  forgotten.  The  skin  is  generally  dry,  harsh,  and  muddy,  and 
the  bowels  constipated.  It  is  such  cases  as  these  which  have  to  be 
carefully  watched  lest  they  give  way  to  the  suicidal  tendencies  which 
are  generally  present. 

In  dementia,  the  lines  of  expression  are  more  or  less  obliterated, 
and  the  vacant,  meaningless  expression  and  smile  or  laugh  are  in- 
dicative of  this  form  of  insanity.  When  the  mind  is  tested,  the  power 
of  memory,  attention,  and  comparison  will  be  found  to  be  partially 
or  entirely  wanting.  It  is  only  in  primary  dementia  that  the  practi- 
tioner will  find  difficulty  in  reaching  a  decision,  and  sometimes  these 
cases  are  very  difficult  to  determine.  In  such  cases  one  of  the  most 
valuable  symptoms  is  loss  of  memory.  The  patient  may,  in  his  con- 
duct and  conversation,  exhibit  no  marked  peculiarities,  but  when  the 
powers  of  his  mind  are  tested  as  to  the  recollection  of  past  events, 
or  even  as  to  the  conversation  of  a  few  minutes  previous,  it  will  be 


72  PSYCHOLOGICAL   MEDICINE. 

found  that  he  has  entirely  forgotten  these  things.  This  form  of  in- 
sanity is  generally  unaccompanied  by  hallucinations  or  delusions,  and 
is  nearly  always  due  to  some  exciting  cause,  such  as  injuries  to  the 
head,  attacks  of  apoplexy,  or  strong  emotional  disturbances.  There 
is  another  variety  of  dementia  which  is  secondary  to  acute  attacks 
of  insanity,  and  which  differs  somewhat  from  primary  dementia.  In 
this  form  of  dementia  we  meet  with  the  remains  of  the  delusions  of 
acute  mania,  and  we  also  find  an  exaggerated  state  of  emotional  feel- 
ing which  remains  after  the  storms  of  acute  mania  have  blown  over, 
and  the  functions  of  the  mind  are  beginning  to  suffer  decay.  The 
diagnosis  of  general  paralysis  is  very  easy  after  we  have  become  ac- 
quainted with  the  disease.  In  the  early  stage  the  most  marked  symp- 
tom is  a  thickness  of  articulation,  particularly  noticeable  when  the 
words  articulated  by  the  patient  are  composed  of  several  consonants, 
when  these  will  be  shuffled  over  in  a  very  characteristic  manner. 
The  lips  of  the  patient  while  he  is  speaking  will  be  seen  to  tremble, 
and  likewise  the  tongue,  if  it  is  protruded  from  the  mouth.  The  gait 
of  these  patients  is  very  characteristic  and  peculiar.  They  shuffle 
along  in  a  manner  that  denotes  at  once  the  want  of  co-ordination  in 
the  muscles  of  the  limbs.  Later  in  this  form  of  insanity  the  power 
over  the  sphincters  is  lost,  the  patient  has  to  be  cared  for  like  an  in- 
fant, and  becomes  a  great  trouble  to  his  attendants. 

There  is  another  class  of  patients  whose  only  manifestation  of  in- 
sanity consists  in  an  abnormal  condition  of  the  moral  power,  and  who 
exhibit  no  obvious  intellectual  aberration  or  impairment.  The  symp- 
toms of  the  mental  disease  in  these  cases  are  limited  to  the  exhibi- 
tion of  morbid  impulses  which  the  intellect  seems  powerless  to  con- 
trol. These  C2^'s,q.'s,  oi  moral  insanity  ■a.x^  sometimes  difficult  to  dis- 
tinguish, and  the  laity  generally  attribute  such  manifestations  to  total 
depravity.  In  such  cases,  we  must  compare  the  patient  with  himself 
when  in  a  state  of  health  and  not  with  any  imaginary  standard  of 
sanity  or  insanity.  We  should  bear  in  mind  in  this  class  of  cases  the 
excellent  definition  of  Dr.  Combe,  who  says  :  "  It  is  the  prolonged 
departure,  without  any  adequate  external  cause,  from  the  state  of 
feeling  and  modes  of  thinking  usual  to  the  individual  when  in  health, 
that  is  the  true  feature  of  disorder  of  the  mind." 

We  have  thus  far  considered  the  diagnosis  of  insanity  only  in  its 
relation  to  the  existence  of  the  disease.  Let  us  finally  look  at  the 
diagnosis  of  recovery,  which  oftentimes  becomes  a  very  delicate  and 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  73 

difficult  task  for  the  examiner.*  We  are  to  determine  whether  the 
patient  has  recovered  so  far  as  to  leave  no  trace  of  insane  ideas  and 
delusions.  We  must  compare  the  man  with  his  former  self  in  a 
measure,  and  see  if  his  natural  tastes,  affections,  impulses,  and  mental 
powers  have  been  restored.  Of  course  we  must  make  an  allowance 
for  a  certain  amount  of  weakness  in  his  intellectual  functions,  just  as 
we  expect  to  find  a  man  weak  bodily  after  an  attack  of  typhoid  fever 
or  other  severe  disease.  We  must  determine  whether  the  man's 
intellectual  faculties,  his  memory,  reason,  and  judgment  are  in  a  state 
to  enable  him  to  take  his  place  and  position  in  active  life.  We  must 
observe  also  whether  his  conduct  is  reasonable  and  quiet.  In  homi- 
cidal or  suicidal  cases  we  must  assure  ourselves  of  the  disappearance 
of  the  propensity.  There  are  many  patients  who,  although  not  re- 
covered, are  in  such  possession  of  their  intellectual  faculties  as  to 
become  very  impatient  of  restraint  and  confinement,  and  no  amount 
of  reasoning  can  make  them  appreciate  the  necessity  for  further  de- 
tention in  an  asylum.  A  marked  case  of  this  character  was  formerly 
under  my  care,  and  illustrated  forcibly  this  class  of  patients,  who,  if 
exposed  to  the  excitement  of  society  before  a  thorough  cure  has  been 
effected,  would  almost  inevitably  have  a  relapse.  This  patient  would 
argue  for  an  hour  at  a  time  very  sensibly  and  forcibly  upon  the  injus- 
tice and  oppression  of  keeping  him  longer  as  a  patient,  and  would  chal- 
lenge any  proof  of  his  insanity,  and  probably  nine  out  of  ten  physicians 
not  acquainted  with  him  would  have  said  that  the  man  was  sane.  He 
would  converse  rationally  upon  all  subjects  until  the  subject  of  religion 
was  introduced,  when  he  would  immediately  reveal  gross  delusions, 
and  would  maintain  with  the  utmost  sincerity  that  he  could  perform  mir- 
acles, and  that  he  was  frequently  the  subject  of  them.  This  shows  the 
importance  of  examining  a  patient  upon  all  conceivable  topics  before 
pronouncing  him  cured.  These  are  the  cases  that  generally  make  their 
friends  and  relatives,  and  particularly  strangers,  feel  that  they  are  un- 
justly detained,  and  are  the  ones  who,  if  they  obtain  their  release  in 
any  way,  publish  their  wrongs,  and  create  in  this  way  ill-founded  prej- 

*  Dr.  Ray  says  a  beginner  in  this  department  of  our  art  hails  every  improvement  as 
the  commencement  of  convalescence,  and  is  apt  to  regard  the  appearance  of  a  few  healthy 
traits  as  the  unquestionable  presage  of  recovery.  It  is  not  until  a  later  period  that  he  be- 
comes acquainted  with  that  peculiar  oscillation  which  marks  the  movements  of  mental 
disease  and  fully  comprehends  the  fact  that  serious  disorder  may  exist  in  connection  with 
many  sound,  healthy  manifestations  of  character.  A  person  may  be  unequivocally  insane, 
retaining  some  flagrant  delusion,  and  yet  be  calm  and  apparently  rational.  With  this  ex- 
ception his  views  are  correct  and  clear. 


74  PSYCHOLOGICAL    MEDICINE. 

udices  against  institutions  for  the  care  of  the  insane.  Generally  speak- 
ing, if  a  person  who  has  been  insane  expresses  himself  as  having  been 
unjustly  treated  and  detained,  and  denies  the  fact  of  his  insanity,  we 
may  be  pretty  sure  that  he  has  not  fully  recovered,  as  persons  who  are 
really  convalescent  are  generally  fully  convinced  that  they  have  been  in- 
sane, and  are  generally  very  grateful  for  the  care  and  attention  that  have 
been  bestowed  on  them,  and  express  themselves  so.  Such  patients 
are  nearly  always  willing  to  be  guided  by  their  physician's  opinion 
as  to  the  proper  time  for  their  discharge,  and  do  not,  as  a  rule,  ex- 
hibit that  intense  restlessness  and  desire  to  return  home  which  is  so 
apt  to  characterize  doubtful  recoveries.  The  first  symptoms  of  re- 
covery are  the  return  of  natural  tastes,  inclinations,  and  affections  in 
the  patient.  Drs.  Bucknill  and  Tuke,  in  speaking  of  symptoms  of 
recovery,  lay  down  the  following  excellent  rules  as  evidences  of  res- 
toration of  the  mind : 

1.  A  natural  and  healthy  state  of  the  emotions. 

2.  The  absence  of  insane  ideas  or  delusions. 

3.  The  possession  of  sufficient  power  of  attention,  memory,  and 
judgment  to  enable  the  individual  to  take  his  part  as  a  free  member 
of  society. 

4.  Tranquil  and  reasonable  conduct;  and  say  regarding  them, 
"  when  these  four  symptoms  of  recovery  coexist  there  can  be  no 
doubt  that  recovery  has  taken  place."* 

Prognosis. 

The  chances  for  cure  are  much  greater  in  recent  than  in  chronic 
cases.  When  treatment  is  delayed  the  patient's  chances  diminish 
greatly,  and  when  treatment  is  delayed  for  twelve  months,  not  more 
than  twelve  per  cent,  generally  recover  their  mental  health.  On  the 
other  hand,  statistics  show  that,  when  the  disease  is  treated  promptly, 
about  fifty  per  cent,  may  be  cured.  The  results  of  treatment  in 
cases  of  insanity  resulting  from  sexual  vice  are  very  unsatisfactory, 
the  disease  tending  toward  dementia  rapidly.     Doubtless  a  certain 

*  Dr.  Ray  believes  that  it  is  not  safe  to  discharge  a  patient  while  he  continues  to  be- 
lieve in  the  reality  of  any  single  notion  or  occurrence  that  was  entirely  the  offspring  of 
fancy,  because  such  a  belief  indicates  morbid  action,  which,  however  circumscribed  at 
present,  is  ever  liable  to  spread,  and  induce  farther  mental  disorder.  Indeed,  the  evil  is 
seldom  so  limited  as  it  seems  to  a  casual  observer.  A  very  marked  remission,  amounting, 
perhaps,  to  a  complete  disappearance  of  ever)'  trait  of  disease,  occurs  within  the  first  month 
of  an  attack,  and  is  often  followed  by  a  renewal  of  the  disease.  This  is  the  result  in  by  far 
the  greatest  number  of  cases. 


DIAGNOSIS   AND    PROGNOSIS    OF    INSANITY.  75 

percentage  of  cases  relapse,  and  there  is  a  greater  tendency  of  hered- 
itary insanity  to  relapse  than  in  any  other  forms,  hereditary  predis- 
position being  very  unfavorable  to  permanent  recovery,  although  you 
may  get  good  results  and  cures  at  first.  The  influence  of  epilepsy 
is  very  unfavorable,  and  of  course  idiocy  and  imbecility  present  an 
unfavorable  prognosis.  General  paralysis  is,  perhaps,  the. most  unfa- 
vorable form  of  insanity  and  is  very  fatal,  cases  generally  dying  in 
about  three  years,  although  death  may  occur  at  a  much  earlier  and 
also  at  a  much  later  period  of  the  disease.  Dementia,  with  the  ex- 
ception of  primary  dementia,  is  also  regarded  as  incurable.  Delu- 
sional insanity  and  hallucinations  and  illusions  of  the  senses  are  rather 
unfavorable  than  otherwise,  as  regards  prognosis.  Acute  mania  is 
a  favorable  form  of  insanity  and  is  recovered  from,  and  also  acute 
melancholia.  Climacteric  insanity  presents  usually  an  unfavorable 
prognosis.  Hysterical  insanity  is  very  curable.  Puerperal  insanity 
is  also  very  curable  if  seen  at  once,  and  a  full  mercurial  cathartic 
given  to  commence  the  treatment,  as  the  cause  of  the  disease  is  sep- 
ticemia, caused  generally  by  absorption  of  retained  products  of  the 
placenta.  Post-febrile  insanity  is  not  very  favorable  as  regards  prog- 
nosis. Successive  attacks  diminish  chances  for  ultimate  recovery, 
although  you  may  have  repeated  relapses  and  recoveries  ensuing. 
The  prognostic  value  of  difference  of  the  pupils  in  insanity  is  not 
great,  according  to  most  authorities,  and  does  not  seem  to  justify  an 
unfavorable  prognosis  ;  paralytic  cases  are  excluded  in  these  remarks. 
Cleanliness,  restored  affections,  return  to  ordinary  tastes  or  habits, 
are  very  favorable  symptoms,  and  also  the  return  of  suspended  secre- 
tions. Prolonged  insomnia  is  an  unfavorable  symptom.  Insanity 
occurring  in  the  young  some  time  before  puberty,  I  believe  to  be  very 
unfavorable,  and  to  tend  to  imbecility.  Respecting  menstruation  in 
women,  the  function  may  be  restored  without  any  corresponding  im- 
provement in  mind,  or  the  mind  may  be  restored  and  the  menses  re- 
main suppressed ;  Dr.  Ray  says,  of  the  return  of  the  menses,  that  "  we 
may  certainly  regard  it  as  a  ground  of  hope  in  reserve." 

Dr.  Blandford,  of  England,  in  writing  on  the  prognosis  of  insanity, 
says:  i.  "  The  general  prognosis  of  insanity  will  depend  on  the  dura- 
tion of  the  existing  disorder.  Perhaps  the  best  established  fact  of 
all  is,  that  the  chances  of  recovery  diminish  in  direct  proportion  to 
the  duration  of  the  malady,  and  that  it  is,  consequently,  of  the  ut- 
most importance  to  place  a  patient  early  under  adequate  and  appro- 
priate treatment.     If  a  twelvemonth  elapses  without  appreciable  im- 


76  PSYCHOLOGICAL    MEDICINE. 

provement,  the  chances  are  decidedly  unfavorable.  If  delusions  or 
hallucinations  remain  fixed  and  unchanged  at  the  end  of  a  year,  es- 
pecially if  there  be  hallucinations  of  hearing,  the  prognosis  is  bad. 
The  chief  exception  is  where  there  is  marked  melancholia.  Patients 
will  recover  from  this  after  long  periods  ;  whereas  such  recoveries 
are  seldom  found  in  insanity  when  depression  is  absent. 

2.  "  When  the  cause  of  the  insanity  has  been  of  long  duration,  the 
prognosis  is  less  favorable  than  when  it  is  a  passing  or  accidental 
form. 

3.  "  Is  the  prognosis  unfavorable  in  hereditary'  insanity?  So  much 
of  the  so-called  simple  insanity  is  hereditary,  that  we  must  admit 
that  recoveries  from  it  are  not  infrequent,  for  it  is  from  this  simple  in- 
sanity that  recoveries  chiejfly  take  place.  Hereditary  insanity  is 
brought  about  by  very  slight  causes,  and  thus  the  prognosis  is  often 
favorable,  and  recovery  takes  place  ;  but  relapse  is  to  be  feared,  and 
the  prognosis  in  a  second  or  third  attack  is  not  nearly  so  good.  In 
this  hereditary  insanit}^,  too,  we  frequently  meet  with  the  cases  of 
recurring  and  '  circular  '  insanitj%  the  progress  of  which  is  most  un- 
favorable. Both  Ray  and  Griesinger  have  remarked  that  the  prog- 
nosis in  hereditary  insanity  is  favorable  only  where  the  individual 
has  previously  been  of  normal  mind.  When  he  has  always  been 
eccentric  or  semi-insane  and  undoubted  insanity  at  last  manifests 
itself,  the  prognosis  is  very  bad. 

4.  "  The  more  acute  the  symptoms,  the  greater  the  cerebral  distur- 
bance and  insomnia,  the  more  favorable  is  the  prognosis,  if  the  case 
is  recent.  Conversely,  the  prognosis  is  bad  when  there  is  little  bodily 
disturbance,  where  sleep  is  present,  the  appetite  normal,  and  the  se- 
cretions unaffected,  especially  if  persistent  delusions  or  an  entire 
moral  change  are  found. 

5.  "As  all  deviation  from  the  ordinary  mental  state  and  disposi- 
tion is  indicative  of  insanity,  so  any  return  to  it  is  a  favorable  sign, 
however  trifling  the  circumstance  may  be. 

6.  "  Improvement,  however  slow,  is  a  good  sign  if  it  be  progres- 
sive. So  long  as  this  goes  on,  recovery  may  take  place ;  but  many 
patients  improve  up  to  a  certain  point  and  then  go  no  farther. 

7.  "  The  age  of  the  patient  must  be  considered.  Young  people 
recover  in  greater  numbers  than  those  advanced  in  life.  The  latter 
recover  if  their  insanity  be  melancholia;  but  if  it  be  mania  with  hal- 
lucinations and  delusions,  and  obscene  conduct  and  ideas,  recovery 


DIAGxXOSIS    AND    PR0GN0SI5    OF    INSANITY.  J  J 

is  rare,  especially  if  the  memory  is  impaired  and  signs  of  approaching 
dementia  are  present. 

8.  "  All  periodicity  in  the   disease,  such  as   exacerbation  and  re- 
missions on  alternate  days,  is  unfavorable." 

Drs.  Bucknill  and  Tuke  in  their  manual  oi  Psychological  Medicine 
say,  respecting  the  diagnosis  of  insanity,  that  no  disease  is  so  varied 
in  its  manifestations  as  insanity.  That  in  no  other  diseases  do  we 
meet  with  such  an  infinite  variety  of  light  and  shade  belonging  to 
their  own  nature,  or  to  their  intermixture  with  other  maladies,  or  to 
the  influence  of  temperament,  of  individual  peculiarities  of  habit, 
or  of  social  position,  and  that,  therefore,  the  diagnosis  of  no  other 
class  of  diseases  taxes  nearly  so  much  the  ingenuity  and  patience 
of  the  physician.  The  physician  is  compelled  to  bring  to  the  inves- 
tigation of  mental  disorders,  a  clear  analytical  conception  of  those 
functions  which  collectively  constitute  mind.  The  diagnosis  of  in- 
sanity presents  itself  either  in  a  strictly  medical  or  in  a  medico-legal 
point  of  view.  If  the  question  is  of  the  former  character,  not  alone  the 
kind  of  medical  treatment,  but  also,  the  question  as  to  whether  the 
patient  has  to  be  deprived  of  his  liberty  comes  up.  If  the  question  is 
medico-legal,  we  may  have  to  appear  either  in  civil  suits  and  proceed- 
ings or  in  criminal  trials.  In  civil  suits  the  distribution  of  property 
to  a  vast  amount,  the  validity  of  wills,  contracts  and  of  other  social 
and  commercial  acts  often  depend  upon  the  decision  of  the  physician  ; 
and  in  criminal  trials  the  frequent  issue  of  the  question  is  the  awful 
one,  whether  a  human  life  shall  be  sacrificed  with  violence  and  igno- 
miny, or  spared  by  establishing  the  plea  of  not  guilty,  on  the  ground 
of  insanity.  Whether  the  question  be  purely  medical  or  medico-legal, 
in  its  bearings  and  apparent  consequences,  the  grounds  of  the  diagnosis 
must  be  the  same,  for,  although  in  criminal  trials  the  nature  of  the 
crime  itself,  and  the  manner  in  which  it  has  been  effected,  must  often 
be  allowed  to  have  no  inconsiderable  weight  in  the  formation  of  the 
judgment,  yet,  these  circumstances  are  essentially  no  other  than  a  part 
■of  the  conduct  of  the  patient;  and  the  conduct  must  be  carefully  es- 
timated, even  v.^hen  the  question  is  most  purely  medical.  The  phy- 
sician is  called  to  see  a  patient  whose  symptoms  have  caused  alarm 
and  anxiety  to  his  friends.  They  wish  to  insure  both  his  safety  and 
their  own,  and  to  provide  immediately  the  treatment  which  affords  the 
best  promise  of  recovery,  and  above  all,  to  have  the  momentous  ques- 
tion decided  for  them  of  confinement  in  an  asylum  or  of  treatment  at 
home. 


yS  PSYCHOLOGICAL    MEDICINE. 

T/ie  diagnostic  value  of  liereditary  tendency  is  great.  The  insanity 
of  one  parent  indicates  a  less  degree  of  predisposition  than  that 
of  a  parent  and  an  uncle,  and  still  less  than  that  of  a  parent  and  a 
grandparent,  or  of  two  parents.  The  insanity  of  a  parent  and  a 
grandparent  with  an  uncle  or  aunt  in  the  same  line,  may  be  held  to 
indicate  even  stronger  predisposition  than  the  insanity  of  both  pa- 
rents. The  influence  of  the  insanity  of  parents  in  creating  a  predis- 
position will  depend,  to  a  great  extent,  upon  whether  it  has  taken 
place  before  or  after  the  state  of  parentage  commenced.  The  in- 
sanity of  a  parent  occurring  after  the  birth  of  a  child,  if  it  arose 
from  a  cause  adequate  to  excite  it  without  previous  predisposition, 
would,  of  course,  be  held  as  of  no  value  in  the  formation  of  heredi- 
tary tendency.  The  insanity  of  brothers  and  sisters  maybe  of  much 
or  of  little  value  as  evidence  of  predisposition,  according  to  the  cir- 
cumstances under  which  it  has  shown  itself  If  several  of  them, 
both  older  and  younger  than  the  patient,  have  become  insane,  the 
fact  tells  strongly  in  favor  of  predisposition,  although  neither  parent 
nor  grandparent  may  have  been  insane ;  since  it  is  well  known  that 
other  conditions  in  the  parent,  besides  that  of  actual  insanity,  may 
create  this  predisposition ;  for  instance,  violent  and  habitual  passion, 
the  debility  of  old  age,  and  most  of  all,  habits  of  intemperance  at  the 
time  of  procreation. 

Tlie  diagnostic  value  of  previous  attacks  is  considerable,  as  few  dis- 
eases more  frequently  recur  than  those  which  affect  the  mental  func- 
tions of  the  brain.  A  slight  and  transient  attack,  however,  respect- 
ing the  real  nature  of  which  there  may  have  been  some  difference  of 
opinion,  will  be  of  very  different  import  from  a  prolonged  attack  of 
decided  character.  The  greater  the  length  of  time  which  has  elapsed 
since  any  previous  attack  has  been  recovered  from,  the  less  will  be 
the  value  of  it  as  an  indication  of  the  nature  of  the  existing  disease. 

TJie  diagnostic  value  of  change  of  habit  and  disposition  is  very  de- 
cided. A  comparison  of  the  present  behavior  and  habits  of  his 
patient  with  those  which  existed  in  a  state  of  health  often  will  afford 
the  physician  a  most  satisfactory  evidence  of  morbid  change  in  the 
brain.  The  natural  character  of  a  man  who  is  insane  is  either  changed 
or  exaggerated.  The  vagaries  of  hysteria  in  a  woman  must  not  be 
mistaken  for  actual  insanity.  The  physician  may  see  in  his  patient 
one  of  four  things  :  first,  a  vacant  and  meaningless  expression,  and 
a  childish  absurdity  of  action,  the  signs  of  dementia,  of  imbecility,  or 
those  of  general  paralysis ;  or  secondly,  a  facial  expression  of  deep 


DIAGNOSIS   AND    PROGNOSIS    OF    INSANITY,  79 

and  concentrated  sorrow  ;  or  thirdly,  indications  in  physiognomy,  or 
demeanor,  of  strangeness  and  irregularity ;  or  fourthly,  no  outward 
indication  of  mental  disease. 

In  melancholia  the  patient  will  readily  converse  on  his  mental 
symptoms.  In  imbecility  and  early  dementia  his  apprehension  is 
not  sufficiently  alert  to  place  him  on  his  guard ;  and  in  mania,  he 
either  suffers  from  head  symptoms,  respecting  which  he  will  readily 
talk  with  the  physician,  or  his  mind  is  actively  engaged  on  some 
project  or  object,  which  will  afford  the  physician  appropriate  topics 
for  conversation.  The  most  difficult  cases  are  those  in  which  differ- 
ences of  opinion  and  of  interest  exist  among  the  members  of  the 
patient's  family,  and  the  patient  has  been  quietly  told  that  it  is  wished 
to  prove  him  insane  and  to  place  him  under  confinement,  and  that 
the  doctor  is  coming  to  examine  him  for  that  purpose. 

There  is  often  a  diagnostic  value  in  peculiarities  of  residence  and 
dress.  The  author  had  a  case  of  general  paralysis  brought  to  him 
for  diagnosis.  The  patient,  a  man  of  wealth,  had  tliree  handsome 
neck-scarfs  on  and  several  valuable  scarf-pins,  and  informed  us  of 
his  desire  to  send  us  one  thousand  boxes  of  cigars  as  a  present.  Said 
he  felt  magnificently ,  that  there  were  few  stronger  men  in  New  York 
than  himself.  At  that  time  he  was  advanced  some  thirteen  months 
in  the  course  of  this  intractable  malady,  and  had  the  shuffling  gait 
and  the  diagnostic  hesitating  stammering  speech  of  a  general  para- 
lytic.    He  was  full  of  delusions  of  wealth  and  grandeur. 

The  diagnostic  value  of  peculiarities  of  bodily  condition  is  prac- 
tically nothing.  There  may  be  emaciation  from  loss  of  rest,  derange- 
ment of  the  alimentic  processes,  a  quicker  pulse  than  normal,  and 
a  tongue  coated  in  the  centre.  The  skin  as  a  rule  is  harsh  and  dry 
and  the  complexion  muddy.  We  frequently  find  disordered  states 
of  the  abdominal  viscera  in  insanity,  and  we  may  not  unlikely  dis- 
cover gastric  or  hepatic  disorder.  Uterine  disease  is  very  frequently 
present.  The  outward  expression  in  the  patient's  features  and  ges- 
tures of  his  inward  psychical  state  of  sadness,  melancholy,  despon- 
dency or  despair,  may  be  very  striking  at  times.  Intensified  expres- 
sions are  seen  in  insanity  of  the  various  emotions,  such  as  pride, 
anger,  fear,  jealousy,  and  the  patient  with  partial  insanity  may  exhibit 
an  unvarying  and  intense  expression  of  any  one  particular  emotion. 
In  mania  the  attitude  is  restless,  the  motions  quick  and  expressive  of 
various  and  chang-eful  emotions,  while  in  melancholia  the  attitude  is 


So  PSYCHOLOGICAL    MEDICINE. 

apt  to  be  fixed  and  the  gestures  slow.     In  imbecility  and  dementia 
we  see  slovenly  postures  and  undecided  and  aimless  movements. 

Respecting  the  physiognomy  of  insanity,  the  extreme  distortion  of 
the  features  produced  by  acute  mania,  or  acute  melancholia,  is  un- 
mistakable. There  is  a  much  greater  expression  of  intense  pain  in 
cerebral  inflammation,  attended  by  maniacal  symptoms,  and  a  more 
prominent  bloodshot  eye  than  in  mania  alone.  In  the  delirium  of 
fever  the  countenance  indicates  low  emotional  force,  while  in  the  de- 
lirium of  mania  the  facial  expression  of  emotional  force  is  highly  ex- 
aggerated. If  there  is  mobility  of  the  facial  muscles  in  the  delirium 
of  fever  it  is  tremulous  and  feeble,  indicating  want  of  power,  while 
in  mania  the  play  of  these  muscles  is  full  of  expression  and  power. 
It  is  vigorous  and  tense,  indicating  a  concentration  of  nervous  force. 
The  wrinkles  in  the  delirium  of  fever  are  the  result  of  emaciation, 
while  in  the  face  of  the  insane  man  they  are  caused  by  the  tense 
contraction  of  the  muscles  of  expression.  There  is  an  apparently 
causeless  and  motionless  play  of  features  often  seen  in  the  insane. 

In  melancholia  the  facial  expression  is  emotional.     In  mania  it  is 
emotional  and  intellectual,  and  marked  by  the  above  characteristics 
of  changeableness  and  inconsistency.     In   dementia  all   expression 
has  disappeared,  and  the  physiognomy  is  vacant  and  meaningless, 
showing  an  absence  of  thought  and  desire.     General  paralytics  ex- 
hibit trembling   lips,  drooping  brows,  and   features   expressive  of  a 
mingled    state    of  imbecility  and    excitement,  eyes  with    pupils    of 
unequal  size,  all  of  which  constitute  a  tout  enseinblc  perfectly  diag- 
nostic to  the  experienced  alienist.     In  primary  dementia  it  is  some- 
times difficult  to  make  a  decided  diagnosis.     The  demeanor  and  con-a 
duct  are  very  slightly   changed,   there   is   nothing  strange   in  thej 
appearance,  but  a  great  diagnostic  sign  is  loss  of  memory  for  very 
recent  events.     In  conversing  with  the  patient  he  may  not  be  ablej 
to  remember  what  he  has  been  talking  about  a  few  minutes  previ-j 
ously.     Injuries  to  the  head  and  apoplexy  most  often  cause  it,  and] 
fever  and  emotional  disturbances,  especially  grief,  will  also  cause  it.j 
There  is  absence  of  delusion,  or  hallucination.     The  physiognomy 
may  be  silly  and  meaningless,  and  the  eyes  may  have  a  meaningless 
look,  and  there  may  be  a  vacant  smile  on  the  lips. 

The  patient  may  also  lose  not  merely  the  power  of  understanding 
anything  like  an  intricate  account,  but  the  value  of  very  simple 
numbers.  These  facts  account  for  the  reckless  expenditures  of 
patients  with  recent  insanity. 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  8 1 

Acute  and  chronic  mania,  and  also  incomplete  mania,  may  be  easily- 
recognized,  or  in  the  latter  case  the  diagnosis  may  be  extremely 
difficult,  and  we  may  have  absolutely  nothing  but  uncontrolled  pro- 
pensities and  extraordinary  conduct  to  guide  us. 

In  chronic  mania,  especially  with  lucid  intervals,  we  may  find  a 
remarkable  strength  of  all  the  intellectual  functions,  in  so  far  as  they 
are  not  affected  by  delusions.  The  perceptive  faculties  are  retained 
in  all  their  activity,  and  the  memory  is  very  good,  and  even  the  judg- 
ment on  matters  unconnected  with  the  delusive  opinions  and  perverted 
emotions  peculiar  to  the  case,  may  not  be  greatly  affected.  The  delu- 
sions may  be  numerous  or  they  may  be  few.  There  is  grave  emotional 
perversion. 

In  incomplete  primary  mania,  there  may  be  a  decidedly  abnormal 
state  of  the  emotions  and  sentiments  without  marked  intellectual 
lesion.  This  symptom  is  constant.  Friends  and  relatives  are  de-: 
tested  and  abused,  and  the  objects  of  natural  affection  overwhelmed 
with  invective,  and,  perhaps,  sacred  things  made  the  subject  of  blas- 
phemy. This  moral  perversion  clearly  indicates  insanity,  but  there 
are  slighter  shades  of  perverted  emotion  which  require  all  the  adroit- 
ness of  the  experienced  alienist  to  discover.  Absurd  opinions  are 
generally  allied  to  perverted  emotions.  Exaggerated  hysteria  may 
confuse  the  diagnosis,  and  it  may  be  mistaken  for  incomplete  primary 
mania,  but  the  age,  sex,  constitution,  and  character  of  the  patient 
will  generally  reveal  the  nature  of  hysterical  attacks  when  they  occur. 
I  had  an  hysterical  patient  who  feigned  that  she  had  the  delusion 
that  there  was  an  animal  in  her  abdominal  cavity,  and  this  was  in 
strict  keeping  with  the  tenor  of  her  life,  for  she  feigned  everything ; 
she,  however,  made  a  beautiful  recovery  by  the  use  of  the  wire  brush 
electrode  with  the  strongest  induced  current.  In  making  the  men- 
tal examination  we  test  the  fundamental  faculties,  the  attention, 
the  memory  and  the  judgment,  and  lead  the  patient  to  give  an  ac- 
count of  his  own  powers  of  body  and  mind  with  reference  to  health, 
to  exercise,  diet  and  study.  Thousands  of  delusions  are  entertained 
by  insane  people  upon  these  subjects.  A  conversation  respecting 
the  patient's  possessions,  his  means  of  livelihood,  and  his  hopes  of 
advancement  will  lead  up  to  delusions  of  pride,  ambition,  and  ac- 
quisitiveness, if  such  exist,  carrying  the  conversation  on  to  his  near 
relatives,  and  friends,  birth  and  parentage,  and  the  patient's  belief 
whether  his  parents  were  his  actual  and  real  parents  will  lead  up  to 
delusions  respecting  imaginary  greatness,  and  any  perverted  emotions 


82  PSYCHOLOGICAL    MEDICINE. 

towards  those  who  ought  to  be  dear  to  him.  His  religious  observ- 
ances may  be  inquired  into  with  the  expectation  of  finding  insane 
delusions  on  this  subject.  Politics  and  science  may  be  made  the 
topic  of  conversation  with  an  educated  man,  and  if  insane  he  will 
hardly  stand  the  test  of  discriminating  inquiry  on  these  and  similar 
subjects.  Indecorous  conduct  towards  the  opposite  sex,  perverted 
appetite  and  unnatural  habits  we  must  learn  of  from  those  who  have 
opportunities  to  discern  them. 

The  diagnosis  of  eccentricity  is  only  likely  to  be  brought  up  in  cases 
of  disputed  wills  or  in  criminal  cases  where  eccentric  conduct  is 
utilized  to  support  the  plea  of  insanity.  There  are  two  forms  of 
eccentricity.  The  one  arising  from  an  excess  of  individuality,  where 
the  individual  is  often  endowed  with  more  than  an  average  portion 
of  good  sense  and  of  moral  courage,  although  his  sense  is  founded 
^pon  reasons  marked  out  by  his  own  mind,  upon  propositions  laid 
down  by  himself,  and  adverse  to  the  common-sense  of  those  among 
whom  his  lot  is  cast,  and  his  moral  courage  is  displayed  by  adhesion 
to  his  own  opinions,  and  by  setting  at  naught  the  ill-founded  ridicule 
of  the  world.  An  eccentric  man  of  this  type  is  further  removed 
from  the  chances  of  insanity  than  most  of  the  sane  people  upon 
whose  prejudices  and  fancies  he  sets  his  heel.  His  intelligence  is 
not  made  the  sport  of  his  passions,  his  emotions  are  under  control ; 
in  short,  he  has  superior  intelligence. 

In  the  second  form  of  eccentricity  the  man  deviates  from  the  ordi- 
nary observances  of  society  from  weakness  of  judgment,  from  love 
of  applause,  and  the  desire  of  drawing  upon  himself  the  attention  of 
others.  His  conduct  is  ill-regulated  and  influenced  only  by  vacil- 
lating emotions,  strong  or  weak,  according  to  the  caprice  of  the  hour. 
He  has  intellectual  powers  of  low  order,  great  desire  of  approbation, 
and  little  individuality.  This  form  of  eccentricity  is  often  nearly 
allied  to  insanity,  and  is  often  premonitory  to  it.  Its  subjects  are  to 
be  found  in  families  tainted  with  hereditary  predisposition  to  mental 
disease,  and  it  merges  so  gradually  and  insensibly  into  mental  disease 
that  the  lines  of  demarcation  are  traceable  only  with  the  greatest  diffi- 
culty, and,  indeed,  often  are  not  to  be  traced  at  all.  In  many  cases, 
however,  the  transition  is  marked  by  perversion  of  the  emotions ;  by 
unfounded  suspicions,  anxieties,  and  antipathies ;  and  also  by  signs 
of  physical  disturbance,  by  sleeplessness,  and  general  feverisliness. 

The  diagnostic  symptoms  of  nielancliolia  are  despondency,  fear, 
and  despair,  existing  in  a  degree  far  beyond  the  intensity  in  which 


DIAGNOSIS    AND    PROGNOSIS    OF    INSANITY.  83 

these  emotions  usually  affect  the  sane  mind,  even  under  circumstances 
most  capable  of  producing  them,  and  in  numerous  instances  existing 
without  any  commensurate  moral  cause  and  often  without  any  moral 
cause  whatever.  The  sad  and  anxious  eye,  the  drooping  brow,  the 
painful  mouth,  the  attenuated  and  careworn  features,  the  muddy 
complexion  and  harsh  skin,  the  inertia  of  body,  the  stooping  and 
crouching  postures,  the  slow  and  heavy  movements,  speak  of  dis- 
tressing oppression  of  the  faculties  and  intense  wretchedness.  In 
other  cases  fearful  anxiety  is  observed,  and  the  eye  becomes  bright, 
the  nostrils  dilated,  the  movements  quick,  irritable,  and  often  im- 
passioned under  the  influence  of  some  vague  terror.  If  the  physi- 
cian can  note  the  above  symptoms  and  can  trace  them  to  a  cause 
productive  of  insanity,  he  will  have  little  difficulty  in  pronouncing 
his  patient  insane,  although  he  can  discover  no  trace  of  delusion. 
In  many  cases  the  patient  is  painfully  aware  of  the  nature  of  his 
malady,  and  seldom  attempts  to  conceal  his  consciousness  of  it  from 
any  considerate  and  sympathizing  inquirer.  Generally,  in  melan- 
cholia, there  are  intellectual  errors  displaying  themselves  by  false 
sensation,  perception,  or  conception ;  in  illusion,  hallucination,  or 
delusion  proper.  There  is  first  emotional  and  secondly  intellectual 
disturbance  in  melancholia.  Respecting  the  differential  diagnosis 
between  hypochondriasis  and  melancholia  Prichard  said  "  that  a 
hypochondriac  is  in  full  possession  of  his  reason,  though  his  suffer- 
ings are  not  so  dangerous  or  so  severe  as  he  supposes;  but  if  he  de- 
clares that  his  head  or  his  nose  has  become  too  large  to  pass  through 
a  doorway,  or  displays  any  other  hallucination,  he  has  become  a 
lunatic ;  his  disorder  has  changed  its  nature,  and  this  conversion 
takes  place  occasionally,  though  by  no  means  so  frequently  as  is 
supposed."  The  apprehensions  of  the  hypochondriac  are  confined 
chiefly  to  his  own  feelings  and  bodily  health.  On  other  subjects 
they  converse  cheerfully,  rationally,  and  justly,  while  melancholiacs 
view  all  things  through  a  gloomy  medium.  The  cause  of  hypochon- 
driasis is  generally  dyspepsia  or  some  morbid  state  of  the  digestive 
organs.  The  love  of  life  and  fear  of  death  characterize  hypochon- 
driasis, while  a  frequent  symptom  of  melancholia  is  disgust  of  life, 
attended  with  desire  to  commit  suicide,  which,  when  motiveless,  is 
one  of  the  surest  marks  of  insanity. 

The  diagnosis  of  monomania  is  easy,  from  the  prominence  of  the 
single  intellectual  error.     The  great  majority  of  cases  are  sequences 


84  PSYCHOLOGICAL    MEDICINE. 

of  or  transformations  from  melancholia.     The  emotional  disturbance 
comes  first ;  the  intellectual  afterward. 

The  diagnosis  of  moral  or  emotional  insanity  proper  is  sometimes 
very  difficult.  This  is,  according  to  Blandford,  a  disorder  of  mind 
shown  by  an  entire  change  of  character  and  habits,  by  extraordinary 
conduct  and  acts,  extravagance  or  parsimony,  false  assertions  and 
false  views  respecting  those  nearest  and  dearest,  but  without  absolute 
delusion.  It  may  follow  epileptic  or  apoplectic  seizures,  or  may  be 
seen  after  a  period  of  drinking.  Its  approach  is  gradual,  as  a  rule, 
rather  than  sudden,  and  the  extraordinary  character  of  the  acts  may 
not  at  first  be  so  marked  as  subsequently.  Friends  wonder  that  a 
man  should  say  this  or  that,  or  should  do  things  so  foreign  to  his 
nature  and  habits,  but  some  time  may  elapse  before  they  can  con- 
vince themselves  that  such  conduct  is  the  result  of  disease;  and  the 
acts  may  be  such  that  many  will  look  upon  them,  even  to  the  last, 
as  signs  merely  of  depravity.  Such  insanity,  of  course,  varies  in 
degree.  When  it  is  well-marked  and  the  conduct  is  outrageous  there 
will  be  no  difficulty  in  the  diagnosis.  But  it  may  be  less  marked. 
It  may  consist  of  false  and  malevolent  assertions  concerning  people, 
even  the  nearest;  of  little  plots  and  traps  to  annoy  others,  in  which 
great  ingenuity  and  cunning  may  be  displayed  ;  and  there  will  be 
the  greatest  plausibility  in  the  story  by  which  all  such  acts  and  allj 
other  acts  will  be  explained  away  and  excused.  It  would  seer 
sometimes  as  if  a  universal  badness  had  taken  possession  of  the  indir 
vidual,  yet  a  badness  so  inexplicable  that  it  can  only  be  looked  upor 
as  madness.  Much  examination  and  opportunity  for  examinatior 
may  be  needful  before  we  can  sign  a  certificate,  for  such  people  are 
often  very  acute  and  quite  on  the  alert.  They  have  no  scruples] 
about  falsehood,  and  will  deny  or  justify  everything  with  which  theyj 
are  taxed.  And  where  the  insanity  is  manifested  in  conduct,  thej 
medical  man  may  never  be  a  witness  of  it,  and  is  obliged  to  receive 
on  hearsay  that  which  the  patient  strenuously  denies.  Careful  in- 
quiry, however,  will  probably  reveal  the  origin  and  cause  of  theJ 
change ;  there  may  have  been  a  period,  though  short,  of  acute 
insanity, — as  acute  mania  or  melancholia, — which  passed  away  an( 
left  this  as  a  permanent  condition ;  or  it  may  be  the  precursor  of 
more  advanced  stage  of  insanity  marked  by  the  ordinary  symptoms 
of  delusion  and  hallucination.  If  the  change  has  been  rapid  ane 
progressive,  and  more  and  more  outrageous  and  eccentric,  it  is  likelj 
that  in  a  short  time  unmistakable  insanity  will  be  displayed.     The 


DIAGNOSIS   AND    PROGNOSIS    OF    INSANITY.  85 

one  constant  and  marked  feature  of  this  insanity  is  the  absence  of 
delusion,  but  we  are  not,  on  this  account,  to  argue  that  the  intellect 
is  sound.  " 

The  hardest  form  of  moral  insanity  to  estimate  and  diagnose  is  the 
congenital  moral  defect — the  moral  imbecility  occasionally  met  with  in 
cases  of  this  reasoning  mania.  These  patients  are  utterly  incapable 
of  telling  the  truth  or  of  understanding  why  they  should  do  so. 
These  are  the  cases  that  commit  crimes  and  are  very  dangerous  to 
the  community  in  which  they  live.  They  may  have  considerable 
intellectual  ability. 

The  diagnosis  of  general  paralysis  is  easy  to  one  familiar  with  the 
disease.  The  best  symptom  for  early  diagnosis  is  the  modification 
of  the  articulation.  It  resembles  the  thickness  of  speech  in  a  drunken 
man,  and  depends  upon  loss  of  power  over  the  co-ordinate  action  of 
the  muscles  of  vocal  articulation.  Words  composed  of  numerous 
consonants,  with  few  vocalic  sounds,  are  articulated  in  a  shuffled 
manner  that  is  perfectly  characteristic.  In  speaking,  the  lips  are 
tremulous,  as  if  the  patient  were  about  to  burst  into  tears.  Protru- 
sion of  the  tongue  is  difficult,  and  it  cannot  be  long  protruded,  and 
while  protruded  it  quivers.  The  brows  droop,  and  the  contraction 
of  the  iris  under  the  stimulus  of  light  is  often  different  in  the  two 
eyes.  The  voice  has  a  peculiar  tremor,  and  the  gait  is  stumbling 
and  shuffling.  Later  on  the  power  over  the  sphincters  is  lost,  and 
finally  the  patient  may  choke  to  death  by  the  stoppage  of  food  in  the 
pharynx.  The  psychical  symptoms  are  generally  delusions  of  wealth 
and  grandeur.  There  is  a  universal  extravagance  of  ideas.  There  is 
loss  of  excito-motor  sensibility. 

The  detection  oi  feigned  insanity  is  very  important.  Those  who 
feign  insanity  generally  overact  their  part.  The  long-continued 
sleeplessness  of  mania  cannot  be  feigned.  Neither  can  the  restless, 
continued  agitation;  the  rapid  pulse;  the  foul  tongue;  the  dry, 
harsh,  inelastic  skin.  If  the  skin  feels  healthy  and  sweaty  from  the 
exertion  of  the  pretender,  and  if  he  sleeps  soundly  and  composedly 
we  may  be  pretty  sure  he  is  feigning.  Chronic  mania  is  more  easily 
simulated  and  more  difficult  of  detection.  Sibbald  says,  respecting 
these  cases,  that  before  deciding  upon  the  reality  of  any  doubtful 
case  of  insanity  all  the  physical  conditions  of  the  individual,  such  as 
the  amount  of  sleep,  the  state  of  the  pulse,  skin,  tongue,  and  diges- 
tive system  generally,  the  conduct  and  the  state  of  health  immediately 
preceding  the  signs  of  insanity  should  be  ascertained.     The  effect  of 


86  PSYCHOLOGICAL    MEDICINE. 

remarks  made  within  hearing  of  the  suspected  person  should  be  ob- 
sen-ed.  One  who  proclaims  his  own  insanity  should  be  distrusted.* 
The  diagnosis  of  concealed  insanity  may,  at  times,  be  made  by 
inducing  a  patient  to  write  to  some  friend,  when  things  that  he  would 
not  speak  of  he  may  write  of  at  some  length,  and  his  delusion  be  made 
very  apparent  A  patient's  conduct  should  be  watched  by  night  as 
well  as  by  day  to  discover  concealed  insanity. 


CHAPTER  V. 

CIVIL    INCAPACITY — LEGAL     TESTS    OF     RESPONSIBILITY HINTS     FOR 

GIVING    TESTIMONY — EXPERT    TESTIMONY,    AND     THE    FUNCTIONS     OF 
EXPERTS    IN    INSANITY. 

Civil  Incapacity — Legal  Tests  of  Responsibility — Hints  i?i  giving 
Evide7ice. — Respecting  the  civil  incapacity  of  an  alleged  insane  man, 
Sibbald  says  that  tlie  acts  of  any  person  either  in  or  out  of  an  asylnm 
may,  hozvevcr,  be  declared  invalid,  if  it  can  be  shotvn  that,  at  the  time  they 
were  performed,  the  person  labored  under  such  an  insanity  as  rendered 
him  incapable  of  performing  them  ratio?ially  and  without  injurious  con- 
sequences. On  this  principle  any  person  may  be  found  to  have  been 
incapable  of  contracting  marriage,  of  executing  a  deed,  contracting  a 
debt,  making  a  will,  or  giving  credible  evidence.  The  principle,  it 
must  be  carefully  noted,  is  not  that  the  mere  existence  of  insanity  in 
the  person  performing  them  invalidates  such  actions,  but  that  if 
the  insanity  has  materially  affected  the  character  and  quality  of  the 
actions,  they  may  be  thereby  invalidated.  This  is  one  of  the  most 
important  principles  that  a  medical  jurist  has  to  keep  in  mind,  as  it 
is  not  an  unfrequent  mistake  to  suppose  that  a  person  is  necessarily 
incapacitated  for  the  performance  of  every  civil  act,  the  moment  he 

*  If  the  simulator  refuses  to  answer  all  questions,  refuses  food,  has  a  stupid  expression 
of  face,  and  remains  obstinately  silent,  it  may  be  at  times  difficult  to  detect  the  simulation. 
Bucknill  and  Tuke  say  that  the  most  important  diagnostic  mark  of  feigned  insanity  is  a 
want  of  coherence  in  its  manifestations ;  their  unconformity,  not  only  with  mental  disease 
in  general,  but  with  the  form  or  variet}'  of  insanity  which  is  feigned  in  particular.  The 
simulator  mixes  the  forms  of  insanity  together. 


CIVIL    INCAPACITY — LEGAL   TESTS    OF    RESPONSIBILITY,    ETC.         8/ 

can  be  proved  to  labor  under  any  condition  to  which  the  term  in- 
sanity may  be  applied.  Perhaps  the  case  in  which  the  validity  of  a 
civil  act  is  most  easily  endangered  by  the  existence  of  any  form  of 
insanity  is  the  contract  of  marriage.  This  proceeding  is  supposed  to 
so  affect  all  the  relations  of  life,  that  almost  any  form  of  unsound- 
ness of  mind  may  be  sufficient  to  interfere  with  that  intelligent  and 
deliberate  consideration,  which  is  essential  to  the  giving  of  rational 
consent.  In  these  cases — medico-legal  cases — it  is  chiefly  impor- 
tant that  the  practitioner  should  distinguish,  ist.  Diseased  perver- 
sion of  the  mental  faculties.  This  includes  all  kinds  of  insanity 
which  are  the  result  of  active  disease,  such  as  the  simple  form  of 
delirium,  mania,  melancholia,  and  monomania.  2d.  Weakness  or 
enfeeblement  of  the  mental  faculties,  resulting  either  from  defective 
development,  disease  or  decay.  This  includes  congenital  imbecility, 
.and  all  the  forms  of  what  is  called  chronic  dementia,  all  those  enfee- 
blements  of  mind  which  are  sometimes  the  remaining  effects  of 
acute  disease,  sometimes  the  concomitants  of  chronic  disease,  and 
sometimes  only  the  mental  phase  of  senile  decay.  In  order  to  es- 
tablish the  incapacity  of  a  person  said  to  labor  under  any  of  these 
forms  of  disease,  it  must  be  necessary  that  an  experienced  physi- 
cian should  not  only  be  able  to  detect  their  characteristic  symptoms, 
but  also  to  show  that  the  performance  of  the  duties,  or  the  exercise 
of  the  rights  under  consideration,  would  be  modified  or  obstructed 
by  the  existence  of  such  disease. 

Marriage. — As  has  been  already  stated,  the  mere  existence  of  any 
form  of  insanity  in  one  of  the  parties,  may  render  a  marriage  contract 
void. 

Civil  Contracts  may  be  held  binding  although  made  by  lunatics. 
If  the  person  with  whom  a  contract  is  made  had  no  knowledge  that 
the  person  contracting  was  insane,  and  if  no  attempt  was  made  to 
take  undue  advantage  of  him,  the  contract  would  be  held  good. 

Wills. — A  person  is  considered  to  be  of  a  disposing  mind,  that  is, 
capable  of  making  a  valid  will,  if  he  knows  the  nature  of  the  act 
which  he  is  performing  and  is  fully  aware  of  its  consequences.  It 
is  in  regard  to  the  making  of  wills  that  the  law  has  carried  out  most 
thoroughly  the  principle  that  the  validity  of  an  act  ought  to  be 
maintained  in  cases  of  insanity,  unless  at  the  time  the  act  was  per- 
formed the  state  of  mind  of  the  agent  can  be  shown  to  render  him 
unfit  to  perform  that  particular  act  in  a  rational  manner.  Persons 
have  made  valid  wills  while  immates  of  lunatic  asylums.     And 'one 


88  PSYCHOLOGICAL    MEDICINE. 

will  was  held  to  be  good,  though  the  testator  had  committed  sui- 
cide within  three  days  after  its  execution.  The  existence  of  de- 
lusion, which  has  been  regarded  by  lawyers  as  of  such  importance  in 
cases  of  alleged  insanity,  does  not  invalidate  a  will;  for  it  has  been 
declared  to  be  "  compatible  with  the  retention  of  the  general  pow- 
ers of  the  faculties  of  the  mind,"  and  to  be  "  insufficient  to  overthrow 
the  will,  unless  it  was  calculated  to  influence  the  testator  in  making 
it."  [We  had,  recently,  under  our  professional  care,  a  young  lady 
of  wealth,  a  case  of  chronic  mania  with  lucid  intervals,  in  whom  the 
natural  affections  were  more  than  usually  lively,  who  possessed  a 
perfectly  clear  idea  of  the  amount  of  property  she  possessed,  and  the 
way  in  which  she  proposed  disposing  of  it  in  the  event  of  her  death, 
and  whose  will,  as  dictated  by  her,  was  as  sane  a  document  as  we 
ever  examined.  Her  testamentary  capacity,  although  an  incurable 
case  of  insanity,  was  perfectly  good,  and  her  will  perfectly  valid.] 

On  the  other  hand  a  will  may  be  invalidated  on  account  of  the  ex- 
istence of  mental  states  which  would  not  be  regarded  as  insanity  from 
either  a  legal  or  medical  point  of  view.  Drowsiness  and  stupor  re- 
sulting from  erysipelas  or  fever,  extreme  weakness  from  cholera  and 
failure  of  memory  in  old  age,  have  all  been  found  sufficient  to  void 
a  will.  If  a  physician  is  called  on  to  be  a  witness  to  a  will,  it  is  his 
duty  to  satisfy  himself  as  to  the  testamentary  capacity  of  the  testa- 
tor. His  subsequent  evidence  in  regard  to  this,  will,  in  case  of  dis- 
pute, be  of  almost  decisive  influence  if  he  has  taken  prpper  means 
of  forming  an  opinion.  In  all  cases,  therefore,  where  there  may  be 
a  possibility  of  doubt,  it  is  well  to  require  the  testator  to  show  that 
without  extraneous  aid,  and  without  referring  to  the  document  itself, 
he  remembers  and  understands  all  the  provisions  of  the  deed. 

Evidetice  of  the  Insane. — Lunacy  was,  until  a  recent  date,  regarded 
by  the  law  as  incapacitating  a  patient  from  giving  evidence  in  court. 
But  according  to  the  much  more  extended  significations  which  the  term 
lunacy  has  received,  it  now  includes  states  of  mind  which  are  compati- 
ble with  testimonial  capacity.  Where  the  judge  is  satisfied  that  the  lu- 
natic understands  the  obligation  of  an  oath,  and  can  give  a  rational 
account  of  such  things  as  happened  before  his  eyes,  the  evidence 
may  be  admitted.  But  the  weight  to  be  attached  to  such  evidence 
will  still  depend  on  the  extent  to  which  it  fulfils  the  conditions  com- 
monly required  to  constitute  credibility.  It  has  been  held,  however, 
that  when  a  person  has  suffered  from  an  attack   of  insanity  between 


CIVIL    INCAPACITY LEGAL   TESTS    OF    RESPONSIBILITY,    ETC.         §9 

the  occurrence  of  a  transaction  and  the  time  he  renders  his  testi- 
mony, his  evidence  cannot  be  admitted. 

Management  of  Property. — Where  persons  are  supposed  to  be  un- 
able, from  unsoundness  of  mind,  to  undertake  the  management  of 
their  own  property,  it  may  be  necessary  that  they  should  be  placed 
under  the  protection  of  the  court;  but  this  proceeding  is  not  usually 
had  recourse  to,  unless,  there  is  urgent  necessity,  or  there  is  a  strong 
probability  that  the  person's  incapacity  will  be  permanent.  It  is  re- 
sorted to  principally  in  chronic  or  congenital  cases,  where  there  is 
no  room  for  doubt  as  to  the  mental  condition  of  the  individual ;  and 
in  cases  of  recent  insanity,  where  it  is  necessary  to  have  recourse  to 
an  asylum  for  the  protection  of  the  individual,  it  may  also  be  nec- 
essary to  obtain  protection  for  his  propert}^  by  the  aid  of  the  court. 
In  giving  evidence  or  framing  a  statement  in  such  a  case,  it  is  im- 
portant, if  incapacity  is  to  be  proved,  to  show  that  the  individual 
has  been  found,  when  placed  in  circumstances  requiring  such  ca- 
pacity, unable  to  perform  the  acts  which  the  management  of  property 
necessitates.  In  cases  of  active  insanity,  it  is  especially  required  to 
show  not  merely  that  there  is  delusion  or  other  symptom  of  insanity, 
but  that  the  insanity  is  of  such  a  nature  as  specially  to  disable  the 
person  from  duly  performing  the  duties  which  would  be  required  of 
him.  Difficulties  most  frequently  occur  in  cases  of  imbecility  and 
dementia;  but  the  verdicts  in  such  cases,  when  disputed,  will  gen- 
erally be  found  to  rest  rather  upon  the  impression  produced  by  evi- 
dence of  the  actual  behavior  of  the  individual  than  the  mere  medical 
view  of  his  mental  condition.  The  most  effectual  aid  that  his  medi- 
cal witness  can  render  in  such  case,  is  to  show  whether  there  are  or 
are  not  such  peculiarities  in  the  conduct  of  the  person  under  inqui- 
sition, as  are  known  to  be  characteristic  of  imbeciles  or  demented 
persons.  In  undisputed  cases,  where  the  duty  of  the  physician  consists 
merely  in  making  an  affidavit,  there  is  special  difficulty  to  be  en- 
countered. Brevity,  scrupulous  accuracy,  and  attention  to  the  fact 
that  such  unsoundness  of  mind  as  involves  incompetency  to  manage 
property  must  be  established,  are  the  most  important  requirements. 
In  England,  a  person  found  by  the  court  to  be  incapable,  is  placed 
under  the  control  of  a  "  committee  of  the  person,"  and  the  property 
under  a  "  com^mittee  of  the  estate."  In  Scotland,  an  application  to 
the  Court  of  Sessions  for  the  appointment  of  a  curator  bonis,  takes 
the  place  of  the  English  inquisition.  The  chief  peculiarities  of  the 
Scotch  process  are,  that  it  is  cheaper,  more  easily  effected  and  more 


go  PSYCHOLOGICAL   MEDICINE. 

easily  annulled,  and  that  it  does  not  affect  the  person  of  the  lunatic. 
By  the  provisions  of  a  recent  act,  the  person  of  an  insane  man  in 
Scotland  may  be  placed  under  the  guardianship  of  the  nearest  male 
relation  found  competent. 

Legal  Tests  of  Responsibility. — Bucknill  and  Tuke  say  in  respect  to 
this,  that  although  in  practice  the  plea  of  insanity  in  criminal  cases 
is  in  a  large  number  of  instances  not  determined  according  to  the 
law  laid  down  by  judges,  but  according  to  the  higher  law  of  hu- 
manity, that  it  is  important  that  students  of  psychological  medicine 
should  know  what  unfortunately  continues  to  be  the  main  legal  test 
of  responsibility  in  criminal  cases, — the  consciousness  or  knowledge 
of  right  or  wrong;  instead  of  being,  as  it  should  be,  whether  in  con- 
sequence of  congenital  defect  or  acquired  disease,  the  power  of  self- 
control  is  absent  altogether,  or  is  so  far  wanting  as  to  render  the 
individual  irresponsible.  As  has  again  and  again  been  shown,  the 
unconsciousnes  of  right  and  wrong  is  one  thing,  and  the  powerless- 
ness  through  cerebral  defect  or  disease  to  do  right  is  another  thing. 
To  confound  them  in  an  asylum  would  simply  have  the  effect  of  trans- 
ferring a  considerable  number  of  the  inmates  thence  to  the  treadmill 
or  the  gallows. 

For  cases  in  which  the  prisoner  was  acquitted  on  the  ground  of 
insanity,  although  knowing  the  nature  and  quality  of  the  act  and 
quite  conscious  of  the  difference  between  right  and  wrong,  the  reader 
is  referred  to  Taylor's  Medical  Jurisprudence,  4th  ed.,  p.  768.  For 
cases  in  which  the  plea  of  irresistible  impulse  was  admitted,  see  p. 
760,  also  p.  262-3  o^  Bucknill  and  Tuke's  Manual  of  Psychological 
Medicine,  4th  ed.  Also  refer  to  "  the  case  of  Henry  Galbites,"  by 
Dr.  Kitching  {Journal  of  Mental  Science,  July,  1867) ;  the  same  wri- 
ter's lecture  on  moral  insanity  {Brit.  Med.  Journal,  1857) ;  "  The  Legal 
Doctrine  of  Responsibility  in  Relation  to  Insanity,"  by  S.  VV.  North, 
M.R.C.S.  {Transactions  of  the  Social  Science  Association,  1864) ;  "  In- 
sanity and  Crime,"  by  the  editor  of  the  Journal  of  Mental  Science, 
1864  (Townley's  case);  "Etude  Medico-legale  sur  la  Folie,"  par  M. 
Tardieu,  1872;  the  work  of  Esquirol  and  Marc,  Brierre  de  Bois- 
mont,  De  la  Folie,  Raisonnante,  etc.,  1867;  "  De  la  Monomanie  de 
Persecution  au  point  de  vue  de  la  Medecine  legale  "  {Ann.  d'Hyg., 
pub.  1852),  and  Lasegue,  "  Memoire  sur  la  Delire  des  Persecutions" 
{Arch.  Gen.  de  Med.,  torn.  27).  A  case  of  delusion  of  persecution 
ending  in  homicide  and  acquittal,  in  which  the  judge's  common-sense 
and  humanity  got  the  better  of  his  law,  will  be  found  in  the  Journal 


CIVIL   INCAPACITY LEGAL   TESTS   OF    RESPONSIBILITY,    ETC.        9 1 

of  Mental  Science,  for  July,  1872.  For  cases  proving  the  presence 
of  the  homicidal  impulse  without  other  symptoms  of  insanity,  see 
article  by  Dr.  Needham  in  the  same  number;  and  for  the  important 
cases  of  Edmunds  and  Watson,  see  April,  1872.  For  case  of  in- 
sane infanticide  and  the  judge's  summing  up,  see  April,  1871.  Mr. 
J.  B.  Thompson's  article  in  the  Journal,  January,  1 870,  and  also  the 
succeeding  one  in  the  October  number,  which  should  be  read  in  con- 
nection with  Despine's  work,  Psychologic  Natiirelle,  1868. 

Hints  in  Giving  Evidence. — Bucknill  and  Tuke  say  respecting  this 
part  of  medical  jurisprudence  : 

1.  That  a  medical  man  is  obliged  to  make  known,  if  asked  in 
court,  the  statements  or  confessions  made  by  a  patient  to  him  {Peake 
on  Evidence,  p.  88 ;  Starkie  on  Evidence,  p.  105  ;  Shelf ord,  p.  81). 

2.  If  a  medical  witness  believes  a  criminal  to  be  insane  and  is 
called  upon  to  give  evidence  to  that  effect,  he  must  not  be  content 
with  stating  his  opinion,  but  must  be  prepared  to  state  the  reasons 
upon  which  that  conclusion  is  based.  For  aid  in  arriving  at  a  judg- 
ment the  reader  is  referred  to  the  chapter  on  the  Diagnosis  of  In- 
sanity. 

3.  The  medical  witness  should  confine  himself  to  a  simple  state- 
ment of  facts,  and  not  allow  himself  to  be  drawn  into  a  metaphysical 
discussion,  or  an  attempt  to  define  insanity. 

4.  If  a  medical  witness  sometimes  wishes  to  fortify  his  view  of  the 
case  by  inducing  the  counsel  to  read  from  medical  works,  and  the 
question  arises  whether  this  can  be  legally  done.  It  has  been  de- 
cided in  one  case  that  "  counsel  was  at  liberty  to  read  as  part  of  his 
speech,  the  opinions  of  a  medical  work,  but  the  jury  would  not  have 
to  decide  the  case  upon  medical  criticism,  but  upon  the  case  and  the 
facts."  The  counsel  in  the  case  alluded  to  then  read  from  a  book  on 
medical  jurisprudence,  in  order  to  show  that  certain  cases  recorded 
there  were  similar  to  the  one  before  the  court.  It  would  appear,  from 
R.  V.  Crouch,  i  Cox,  C.  C,  94,  that  the  opinions  of  a  medical  writer 
cannot  be  stated  in  an  address  to  the  jury,  but  the  judge  in  the  case 
alluded  to  did  not  distinguish  between  these  and  cases. 

5.  In  regard  to  any  notes  the  medical  witness  may  have  taken  of 
the  prisoner's  state,  he  may  only  make  use  of  those  in  court  which 
he  has  committed  to  paper  at  the  time  he  examined  the  prisoner. 

6.  It  must  not  be  forgotten  that  the  prisoner  may  be  sane  when 
examined  by  the  physician,  and  yet  may  have  been  insane  when  he 
committed  the  deed,  and  vice  versa. 


92  PSYCHOLOGICAL   MEDICINE. 

Expert  Testimony  and  the  Functions  of  Experts. — Many  of  the  com- 
munity, as  the  late  Dr.  Ray  has  shown,  completely  ignore  the  exact 
purpose  of  skilled  testimony  in  a  judicial  proceeding  and  the  func- 
tions of  an  expert.  They  are  apt  to  bring  forward  the  timeworn 
objection  to  expert  testimony,  viz.,  that  as  the  experts  are  engaged 
by  one  or  the  other  of  the  litigant  parties  they  thus  necessarily 
testify  under  a  bias,  and  consequently  are  not  trustworthy.  This 
would  imply  that  there  is  a  distinct  understanding  as  to  what  any 
given  expert  shall  say,  before  he  has  heard  a  word  of  the  evidence 
on  either  side.  An  expert's  opinions,  as  Dr.  Ray  has  said,  are  worth 
money,  but  it  does  not  follow  that  his  opinions  are  corruptly  bought. 
Why  should  a  fair  reward  for  professional  services  obscure  an  ex- 
pert's perception  of  truth  ?  Experts  necessarily,  according  to  the 
present  law,  which  we  hope  to  see  reformed  (see  chapter  on  "  the 
necessity  for  a  reform  in  the  introduction  of  expert  testimony  where 
insanity  is  alleged  as  a  defence"),  testify  in  the  interest  of  a  party; 
but  that  fact  Dr.  Ray  conclusively  proved  does  not  imply  an  unwor- 
thy bias.  The  counsel  lay  before  the  expert  the  evidence  to  be  pro- 
duced before  him  as  far  as  they  can,  and  the  honest  expert  invaria- 
bly tells  the  counsel  either  that  if  he  can  prove  the  facts  as  he  states 
them  he  has  a  good  cause,  or  he  tells  him  that  even  if  he  does  prove 
such  facts  they  would  not  warrant  the  construction  he  wishes  to  put 
upon  them,  and  that  his — the  expert's — testimony  would  not  help 
him.  Generally  speaking,  it  is  as  Dr.  Ray  said,  that  if  an  expert's 
testimony  is  wholly  and  unconditionally  in  favor  of  one  side  only,  it 
is  merely  because  this  result  is  warranted  by  the  facts.  An  honest 
expert  will  moreover  warn  the  counsel  that  the  evidence  as  brought 
out  on  trial  may  oblige  him  to  modify  his  opinion. 

An  expert  is  one  who  gives  his  time  and  attention  entirely  to  a 
particular  pursuit,  and  he  is,  therefore,  to  be  recognized  as  an  expert 
in  questions  relating  to  that  pursuit,  to  the  exclusion  of  those  who 
have  attended  to  it  incidentally  as  a  subordinate  part  of  a  more  gen- 
eral department  of  inquiry. 

Tlie  functions  of  an  expert  are  to  appear  in  court  to  give  an  opin- 
ion, based  either  on  his  acquaintance  with  the  party  whose  mental 
or  physical  condition  is  under  investigation,  or  upon  a  medical  ex- 
amination of  him  which  he  has  made,  or  upon  a  hypothetical  case 
stated  to  him  in  court.  The  expert  is  wanted  in  court  to  give  his 
opinion  on  facts  proved  or  upon  a  case  hypothetically  staged.  An  opin- 
ion, I  should  define,  as  the  statemejit  of  what  certain  facts  indicate  to 


CIVIL    INCAPACITY — LEGAL   TESTS   OF   RESPONSIBILITY,    ETC.        93 

the  expert  himself.  Therefore,  on  a  trial,  I  do  not  think  an  expert 
should  give  his  opinion  upon  facts  proved  by  a  witness  unless  he  hears 
all  the  testimony  of  such  witness.  The  old  practice  where  the  expert 
heard  all  the  evidence  given  at  the  trial,  and  then  was  asked  for  his 
opinion  founded  on  that  evidence,  supposing  it  to  be  true,  was,  I  think, 
better  calculated  to  elicit  a  well-considered  opinion  than  the  new 
change,  where  the  counsel  on  each  side,  out  of  the  facts  that  have  ap- 
peared in  evidence,  construct  a  hypothetical  case  as  fairly  as  will  best 
serve  their  purpose,  and  no  more.  In  such  cases  the  expert  may  be 
obliged  to  assent  to  the  propositions  of  both  sides,  as  Dr.  Ray  has 
shown,  and  thus  apparently  stultify  himself.  This  is  due  to  a  twist- 
ing and  coloring  of  facts.  Sometimes  unfortunately  the  manner  in 
which  an  expert's  opinion  is  elicited  is  deliberately  calculated  to  over- 
whelm it  with  discredit.  Able  counsel  use  all  their  professional  as- 
tyteness  to  deprive  of  its  proper  weight  with  the  jury,  says  Dr.  Ray, 
the  most  honest  and  truthful  expressions  of  opinion,  and  if  we  had 
a  healthier  public  sentiment  which  would  make  the  judge  keep  a  cross- 
examination  within  its  proper  limits  and  restrain  the  license  of  counsel, 
the  public  would  have  less  reason  for  distrusting  and  sneering  at  ex- 
pert testimony.  The  judge's  question  to  determine  whether  a  witness 
offered  as  a  mental  expert  has  the  legal  qualification  to  entitle  him  to 
testify  as  such  should  be  :  "  Do  you  give  your  time  and  attention  en- 
tirely to  a  particular  branch  of  medicine,  and  is  that  mental  or  psy- 
chological medicine  ?"  This,  and  nothing  else,  is  needed  to  consti- 
tute an  expert  in  mental  medicine.  He  should  then  in  any  given 
case,  give  his  opinion  on  the  case  from  the  examination  he  has  made ; 
his  observation,  experience  and  professional  reading.  He  necessarily 
forms  an  opinion  from  this  combination. 

Dr.  Ray  recommended,  in  1873,  that  the  testimony  of  experts  be 
given  in  writing  and  read  to  the  jury  without  any  oral  examination. 
It  would  thus,  he  said,  be  deliberately  prepared,  its  explanations 
well  considered,  and  its  full  force  and  bearings  clearly  discerned.  It 
would  go  to  the  jury  on  its  own  merits,  no  advantage  being  gained 
by  either  party  by  the  superior  adroitness  of  counsel  in  embarrassing 
the  witness  and  pushing  his  statements  to  a  false  or  ridiculous  con- 
clusion. It  would  work  no  injustice  to  either  party,  and  it  could  be 
managed  without  additional  inconvenience.  There  could  be  no  dif- 
ficulty in  civil  cases  where  both  parties  consent  to  such  an  arrange- 
ment. Dr.  Ray  says  :  "  Judges  should  not,  as  they  sometimes  have 
been  known  to  do,  disregard  their  proper  functions  and  assume  the 


94  PSYCHOLOGICAL    MEDICINE. 

part  of  an  expert,  and,  in  cases  of  disputed  sanity,  pronounce  a  man  to 
be  sane  and  safe  to  be  at  large  in  spite  of  the  declarations  to  the  con- 
trary of  men  long  conversant  with  the  discourse,  conduct,  ways,  and 
manners  of  the  insane."  The  whole  subject  of  expert  testimony  needs 
to  be  lifted  up  to  a  higher  plane  than  it  now  occupies,  by  the  mutual 
efforts  of  lawyers,  physicians,  and  public  sentiment.  The  revolution 
in  the  management  of  the  insane  has  produced  among  its  legitimate 
effects  a  better  knowledge  of  insanity.  Respecting  written  testimony 
I  would  add  that  in  the  celebrated  Parish  will  case,  reported  by  Ray 
in  his  Contributions  to  Mental  Pathology ,  p.  316,  where  Henry  Parish, 
a  prosperous  New  York  merchant,  made  his  will  in  1842,  being  then 
fifty-four  years  old,  on  trial  the  surrogate  wisely  determined  that  the 
opinions  should  be  given  in  writing,  with  the  understanding  that, 
though  not  clothed  with  the  authority  of  legal  evidence,  they  would 
be  carefully  considered  and  credited  with  all  the  weight  to  which 
they  were  really  entitled.  This  enabled  the  expert  to  utter,  as  Dr. 
Ray  showed,  what  is  impossible  in  the  usual  method  of  examination 
and  cross-examination,  his  opinions  and  the  reasons  for  opinions, 
with  that  coherence  and  logical  relation  absolutely  necessary  to 
show  their  full  force  and  significance.  Mr.  Parish  made  his  will,  in 
1842,  disposing  of  some  $750,000.  He  went  to  Europe  in  1843,  and 
had  an  apoplectic  attack,  from  which  he  shortly  recovered  and  con- 
tinued as  well,  apparently,  as  ever,  both  in  body  and  mind,  until  the 
19th  of  July,  1849,  when  he  had  another  apoplectic  attack,  much 
more  severe.  In  about  a  fortnight  he  was  out  of  immediate  danger, 
but  never  recovered  his  ordinary  condition.  His  right  side,  including 
the  upper  and  lower  limbs,  was  found  to  be  somewhat  paralyzed  ;  the 
power  of  articulation  was  lost ;  and  his  natural  elasticity  and  vigor 
were  gone.  These  traits  continued  with  little  change  until  he  died, 
in  1856.  Epileptic  fits  occurred  within  a  few  months  of  the  apoplec- 
tic attack  of  July,  1849,  ^^  intervals  ranging  from  eight  days  to  six 
months  or  more.  On  the  29th  of  August,  1849,  he  subscribed  his 
cross  in  lieu  of  a  signature  to  a  codicil  to  his  will.  On  the  15th  of 
September,  1853,  a  second  codicil  was  subscribed  in  like  manner, 
and  on  the  15th  of  June,  1854,  a  third  codicil,  substituting  his  wife 
in  place  of  Daniel  and  James  Parish  as  residuary  legatee.  These 
codicils  were  contested  in  the  Surrogate's  Court  on  the  ground  that 
when  they  were  made  the  testator  had  not  a  testamentary  capacity. 
His  mental  condition  during  the  period  between  the  attacks  in  1849 
and  his  death  in  1856  was  that  of  but  a  small  measure  of  mental 


GENERAL    PARALYSIS    OF   THE    INSANE,  95 

capacity.  He  was  reduced  to  an  almost  vegetative  existence.  There 
was  ample  proof  of  mental  infirmity,  of  dementia,  or  imbecility.  He 
was  plainly  an  insane  man,  without  mind  enough  left  to  constitute 
testamentary  capacity. 


CHAPTER  VI. 

GENERAL    PARALYSIS    OF    THE    INSANE. 

(Syn. — Paralytic  Dementia  ;  Progressive   General  Paresis  ;  Paralysie  general  des 

alien  is.) 

In  writing  on  this  very  interesting  form  of  mental  disease  we  may 
define  it  as  a  disease  characterized  by  general  and  progressive  loss  of 
co-ordinating  power  over  the  muscles,  especially  those  of  speech  and 
locomotion,  combined  with  mental  enfeeblement,  always  tending  to 
dementia,  and  characterized  by  a  sense  of  well-being  or  actual  delu- 
sions of  an  exalted  character.  It  is  doubtless  true  that,  in  certain 
states  of  the  brain,  mental  action  or  the  actions  of  the  higher  centres 
of  the  brain  may  become  at  times  automatic,  and  be  performed  with- 
out the  intervention  of  consciousness.  A  constant  repetition  of  any 
given  mental  action  causes  it  to  become  organically  registered  in  the 
brain  centres,  so  that  while  at  first  a  series  of  thoughts  is  performed 
consciously  by  the  individual,  it  ultimately  becomes  reflex,  respond- 
ing to  the  recognized  stimulus  without  consciousness  and  indepen- 
dent of  any  effort  or  intervention  of  consciousness.  It  is  to  some 
injury  of  this  mind-power  that  we  must  look  for  an  explanation  of 
the  mental  symptoms  of  general  paralysis.* 

Two  classes  of  mental  actions  will  necessarily  be  involved  in  this 
disease.  First,  those  which  are  of  so  recent  an  origin  as  not  to  have 
become  organically  registered  ;  and  second,  those  which  are  still 
unable  to  be  performed  without  conscious  interference.     One  of  the 

*  General  paralysis  may  be  due  to  excessive  mental  labor,  great  anxiety,  alcoholic  or 
venereal  excess,  or  to  any  great  and  continued  strain  upon  the  centric  nervous  system. 
Blows  on  the  head  and  sunstroke  may  produce  it,  and  it  attacks  by  preference  males  be- 
tween thirty  and  fifty  years  of  age.  Sleeplessness,  restlessness,  depression  followed  by 
exaltation,  enfeeblement,  and  extravagance  of  thought  and  action  are  early  and  marked 
symptoms. 


g6  PSYCHOLOGICAL    MEDICINE. 

most  prominent  instincts  or  ideas  in  the  human  mind  is  the  import- 
ance of  self.  In  a  healthy  state  we  draw  up  and  surround  ourselves 
with  an  ideal  self  which,  if  we  are  healthy-minded,  finds  no  expres- 
sion. If  the  power  to  which  all  mental  processes  are  due  be  im- 
paired, those  actions,  among  others,  will  be  affected  which  are  the 
most  detailed  and  elaborate,  the  most  varied,  the  least  rigidly  defined, 
and  the  least  organically  registered.  Of  all  mental  processes  those 
involved  in  the  consideration  of  self  are  at  once  the  most  general, 
extensive,  and  complicated,  as  well  as  the  most  vague  and  undefined. 
Self  occupies  in  the  mind  the  widest,  most  frequent,  and  most  capri- 
cious attention.  As  in  general  paralysis  this  mind-power  is  the  seat 
of  the  main  lesion,  the  psychical  processes  concerned  in  the  con- 
sideration of  self  will  be  the  first  involved,  and  will  present  the  most 
prominent  symptoms.  In  general  paralysis  the  ideal  self  runs  riot; 
the  man  is  not  as  he  is,  but  as  he  has  pictured  himself  and  as  he  would 
have  himself  be.  In  the  inception  of  his  disease  the  patient  feels 
himself  "bang-up"  and  "perfect."  Everything  is  "elegant"  and 
rose-colored.  His  wealth  is  unbounded,  and  he  orders  "  a  million  " 
cigars  and  orders  palaces  built  of  gold  and  diamonds  with  the  utmost 
indifference  and  nonchalance,  thoroughly  believing  in  his  capacity  to 
do  all  these  things.  The  patient's  delusions  are  markedly  progres- 
sive in  number,  absurdity,  and  exaggeration.  Being  rather  feeble,  he 
imagines  himself  capable  of  immense  sustained  exertions.  In  gen- 
eral paralysis  the  mental  processes  which  are  the  most  automatic  are 
the  last  to  be  affected,  and  the  patient  entertains  perfectly  reasonable 
ideas  about  his  actual  self,  and,  although  possessing  thousands  of 
ideal  dollars  and  estates,  will  tell  you  correctly  that  he  earns  but  ten 
dollars  per  week,  as  this  idea  has,  from  frequent  and  constant  repeti- 
tion, become  automatic.  In  the  same  manner  a  patient  under  my 
care  tells  me  correctly  that  his  suit  of  clothes  cost  him  fifteen  dollars 
in  London,  and  in  the  same  breath  says  that  he  has  ordered  a  silk- 
velvet  suit  with  diamond  buttons.  At  the  present  moment  he  con- 
siders his  health  perfect,  but  acknowledges  that  in  the  past  he  has 
had  many  sicknesses  and  infirmities.  Matters  of  recent  occurrence, 
which  have  not  had  opportunities  for  repetition,  and  so  have  not  be- 
come organically  registered  and  automatic,  and  that  consequently 
involve  consciousness,  are  far  more  dependent  upon  mind  than  mat- 
ters of  earlier  date  w^hich  have  been  so  frequently  repeated  as  to 
acquire  automaticity.  The  patient,  therefore,  while  stating  with 
accuracy  events  and  detailed  accounts  of  the  past,  can  give  but  a  very 


GENERAL   PARALYSIS    OF   THE    INSANE.  ^7 

vague  and  confused  account  of  the  events  of  the  last  few  days  or 
weeks.  This  defect  in  memory  is  consequently  one  of  the  most 
noticeable  symptoms  in  the  early  stage  of  the  disease,  and  we  observe 
it  particularly  in  persons  of  methodical  habits.  Leaving  this  inter- 
esting field  of  the  psychology  of  general  paralysis,  we  proceed  to 
notice  its  pathology. 

Pathology  of  General  Paralysis. — The  pathology  of  general  paraly- 
sis is  very  obscure,  and  invites  especial  attention  at  the  hands  of  the 
profession.  Dr.  Magnan,  a  distinguished  physiologist  and  psycholo- 
gist, the  superintendent  of  a  Paris  insane  asylum,  considers  that  the 
fundamental  lesion  of  this  disease  is  a  generally  diffused  interstitial 
encephalitis,  which  involves  accessory  structural  changes  of  various 
character.  He  regards  the  primary  and  most  palpable  form  of  the 
interstitial  degeneration  as  colloid,  where  the  transformed  matter  is 
presented  under  the  aspect  of  a  hyaline  substance,  semi-transparent, 
slightly  refractory,  and  at  certain  points  of  a  bluish  tint.  When  ex- 
isting in  isolated  masses  of  small  size,  it  preserves  the  form  and 
aspect  of  whatever  cerebral  elements  it  may  have  invaded.  This  pro- 
duct of  inflammation,  which  Dr.  Magnan  does  not  claim  to  be  tu- 
bercular, is  not  of  a  fatty  nature,  because  insoluble  in  ether  or  chlo- 
roform. It  is  not  amyloid,  because  unaffected  by  tincture  of  iodine 
or  solutions  of  potassa  and  soda,  and  is  dissolved  in  strong  acetic 
acid.  It  is  not  organic,  as  there  is  no  reaction  with  hydrochloric 
acid.  Its  solubility  in  hot  water,  especially  when  potassa  or  soda  is 
added,  is  supposed  to  establish  the  possession  of  a  peculiar  chemical 
composition.  In  examining  the  cerebrum  as  the  principal  seat  of 
paresis,  Magnan  claims  priority  in  having  determined  the  ependyma 
of  the  ventricle  as  the  centre,  or  perhaps  one  of  many  centres,  of  that 
destructive  process  which  is  indicated  by  the  symptoms  of  general 
paralysis,  which  affects  all  parts  of  the  encephalon  and  produces 
those  secondary  pathological  appearances  that  have  previously  been 
identified  as  the  cause  of  the  disorders  of  mobility  and  sensibility. 
The  progress  of  the  morbid  degeneration  from  the  point  where  the 
ventricles  have  become  dilated,  their  ependyma  thickened,  when  their 
surface,  especially  in  the  fourth  ventricle,  is  covered  with  granula- 
tions, is  probably  upwards  along  the  connective  as  well  as  involving 
all  tissues,  and  is  gradual  and  insidious,  and  can  only  be  traced  by  the 
more  advanced  alterations  in  structure.  (It  is  proper  to  state  here 
that  Dr.  Boyd,  late  physician  and  superintendent  of  the  Somerset 
County  Lunatic  Asylum,  in  England,  disputes  Dr.  Magnan's  claim 

7 


98  PSYCHOLOGICAL    MEDICINE. 

to  the  priority  in  the  discovery  of  the  pathological  changes  in  gene- 
ral paralysis,  calling  attention  to  his  observations,  made  about  thirty 
years  ago,  in  the  second  annual  report  of  the  Somerset  County  Asy- 
lum.) This  interstitial  irritation  of  the  brain  in  general  paralysis, 
however  it  is  disseminated,  is  propagated  by  nuclear  proliferation,  and 
invades  the  white  matter  in  common  with  the  cortical  substance,  and 
also  the  capillaries,  which  are  thickened,  tortuous  and  massed  together. 
The  cells  of  the  cortical  portion  are  sometimes  found  infiltrated  with 
granulations,  but  preserving  their  form.  This  is  found  in  the  third 
stage  of  the  disease.  It  is  in  the  middle  and  inferior  portions  of  the 
gray  matter  that  the  cells  are  observed  to  have  brilliant  nuclei  tending 
toward  colloid,  while  their  normal  aspect  is  preserved.  The  walls  of 
the  cells  nearest  the  lesion  are  transformed  into  a  shining,  refractory, 
hyaline  substance,  the  colloid  infiltration  having  been  propagated  to 
both.  The  microscopic,  as  well  as  the  naked-eye  appearances,  may 
appear  first  in  the  brain  and  subsequently  in  the  medulla,  or  they  may 
appear  first  in  the  medulla  and  afterwards  in  the  brain  ;  and  they  may 
also  appear  in  both  simultaneously.  If  the  brain  is  primarily  attacked 
the  psychical  signs  predominate  or  are  exclusively  manifested.  If 
the  medulla  be  the  primary  seat  of  the  disease,  muscular  pain,  tremor 
and  ataxic  symptoms,  spreading  gradually  to  the  lips  and  tongue,  dis- 
turbance of  the  internal  viscera  corresponding  to  the  portion  of  the 
spinal  column  involved,  precede  alienation  and  increase  the  difficulty 
of  diagnosis.  Finally,  when  the  whole  cerebro-spinal  axis  participates 
at  once  in  the  colloid  degeneration,  the  characteristic  indications  of 
paresis  will  appear  simultaneously  or  in  rapid  succession.  It  is  impor- 
tant for  us  to  bear  in  mind  that  the  colloid  degeneration  upon  which 
Magnan  insists  is  far  from  being  constant  in  paresis,  and  we  meet  with 
it  in  other  diseases  remotely  connected,  or  perhaps  in  no  degree  con- 
nected with  paresis.  For  instance,  the  ependyma  of  the  fourth  ventri- 
cle has  been  found  to  be  the  seat  of  the  same  changes  as  in  paresis 
after  muscular  atrophy,  chronic  alcoholism,  senile  dementia,  tetanus, 
and  also  after  tubercular  meningitis.  I  will  now  cite  as  concisely  as 
possible  the  opinions  of  the  highest  authorities  relative  to  the  pathol- 
ogy of  the  disease  under  question.  Bayle  designated  the  disease 
chronic  arachnitis.  Calmeil  considered  it  as  a  diffused  chronic  peri- 
encephalitis, and  held  that  it  was  of  inflammatory  origin.  Baillarger 
observed  two  sets  of  anatomical  alterations,  congestion  of  the  mem- 
branes and  chronic  hydrocephalus,  with  atrophy  and  softening  of  the 
brain.    Burnet  and  Lancereaux  speak  of  a  neo-membrane,  or  a  pachy- 


GENERAL    PARALYSIS    OF   THE    INSANE.  99 

meningitis,  the  formation  of  which  they  explain  by  the  exudation  of 
a  parietal  layer  from  its  walls,  which  is  insensibly  organized  and 
which  bears  the  marks  of  fatty  degeneration.  The  rupture  of  these 
vessels  leads  to  the  occurrence  of  arachnoid  cysts.  Erlenmayer  ex- 
plains the  atrophy  which  has  been  noticed  by  the  successive  and 
repeated  effusions  of  serum,  the  nervous  elements  being  replaced  by 
an  amorphous  substance.  Frerichs  considers  the  induration  of  the 
gray  matter  as  connecting  the  pathological  condition  with  sclerosis. 
The  alterations  in  the  white  matter  consist  of  hardening  or  softening, 
increase  of  fluid  of  the  ventricles  and  thinning  of  their  parietes, 
which  resemble  indurated  ependyma.  M.  Luys,  a  very  able  French 
investigator,  believes  that  in  the  softening  of  the  cortical  substance 
of  the  cerebellum  may  be  discovered  the  source  of  general  paralysis, 
but  Magnan  asserts  that  this  conviction  of  M.  Luys  is  founded  on 
exceptional  cases.  M.  Luys  gives  as  the  result  of  his  microscopic 
investigations  the  following  results,  viz. :  The  vessels  of  the  pia  mater 
are  of  considerable  size,  the  walls  of  the  capillaries  incrusted  with 
granulations,  the  surface  of  the  pia  mater  presenting  scattered  cell- 
granules  and  molecules  and  extravasated  blood-globules.  The  gray 
substance  is  greatly  developed,  with  palpable  vascular  arborizations, 
often  in  the  form  of  a  plexus.  The  calibre  of  the  capillaries  is 
almost  always  contracted  by  the  incrustation  of  minute  granules,  or 
by  cells,  deposited  chiefly  at  the  bifurcations,  which  are  of  irregular 
shapes  and  break  down  and  discharge  their  contents.  The  nerve- 
tubes  are  malformed,  their  contents  escape,  and  they  present  little 
more  than  a  mass  of  debris. 

Rokitansky  has  detected  three  distinct  pathological  appearances  : 
1st.  Where  a  mass  of  connective  tissue  embraces  in  its  network  the 
nervous  element,  and  in  chronic  cases  is  stiff,  fibrous,  and  induces  ad- 
hesion of  the  pia  mater.  2d.  The  tubes  are  varicose  and  broken, 
while  the  cells  appear  swollen.  3d.  The  presence  of  amyloid  or  col- 
loid bodies.  Wedl's  observations  are  as  follows :  That  contraction 
of  the  capillaries  and  small  bloodvessels,  in  consequence  of  the  cells 
upon  their  walls,  leads  to  obliteration,  their  conversion  into  bands  of 
connective  tissue,  and  the  consequent  impairment  of  the  nutrition  of 
the  part.  Dr.  Ertzbischoff  attributes  the  hypersemia  of  the  cortical 
layers  to  the  extreme  development  of  the  embryoplastic  element  in 
the  capillaries,  which,  by  compressing  the  vessels  without  and  within, 
diminishes  and  ultimately  destroys  the  cavity.  This  stasis  necessi- 
tates granulations  and  adhesion.     The  majority  of  the  German  pa- 


lOO  PSYCHOLOGICAL    MEDICINE. 

thologists  localize  the  disease  in  changes  of  the  walls  of  the  vessels 
and  in  the  development  of  the  connective  tissue.  Meschede  sees  the 
essential  characteristics  of  paresis  in  the  degeneration  of  cerebral 
cells,  especially  those  of  the  cortical  substance,  Avhich  he  depicts  as 
of  abnormal  shape  and  filled  and  surrounded  with  fatty  and  pigmen- 
tary granulations.  Lockhart  Clarke  speaks  of  the  conversion  of  the 
cells  of  the  convolutions  into  pigmentary  bodies,  irregularly  shaped 
and  about  to  break  up.  Contemporaneously  with  this  change,  the 
spinal  marrow,  especially  in  chronic  cases,  is  softened  to  the  consist- 
ency of  cream,  or  there  may  be  a  granular  degeneration  in  its  gray 
matter  or  in  its  surroundings.  Westphal  has  discovered  in  some 
cases  granulations  in  the  posterior  columns  of  the  spinal  cord,  which 
did  not  extend  higher  than  the  peduncles  of  the  cerebrum,  so  that 
the  alteration  could  not  be  regarded  as  secondary,  or  as  proceeding 
from  the  pathological  condition  of  the  convolutions.* 

The  course  of  general  paralysis  may  very  properly  be  divided  into 
four  stages  : 

1.  That  of  delirium,  with  or  without  slight  physical  lesions. 

2.  That  of  defective  co-ordination  of  movement,  exaggerated  sen- 
timents, alterations  in  the  secretions,  with  continued  delirium. 

*  Although  we  have  the  greatest  respect  for  the  opinions  and  observations  of  all  the 
distinguished  observers  we  have  mentioned,  we  think  they  have  all  paid  too  little  atten- 
tion in  their  researches  to  the  condition  of  the  spinal  cord  in  general  paralysis ;  our  own 
investigations  have  been  limited  to  perhaps  too  few  cases  to  draw  forcible  deductions  from, 
but  they  have  convinced  us,  personally,  that  whether  primarily  or  secondarily  to  cerebral 
change  the  spinal  cord  is  always  affected,  and  that  the  changes  in  it  are  constant  and 
peculiar.  We  think  these  changes  often  primary.  We  call  attention  to  one  of  the  micro- 
photographs  in  this  work,  showing  atrophy  of  nerve-cells  of  the  posterior  columns,  with 
plates  of  new  connective  tissue  of  irregular  size.  The  lateral  columns  are  also  affected 
in  their  posterior  section ;  and  the  posterior  columns  and  the  posterior  part  of  the  lateral 
columns  may  be  unitedly  affected.  We  also  call  attention  to  another  micro-photograph 
depicting  a  change  not  unlike  that  we  meet  with  in  myelitis,  with  marked  softening,  evi- 
dently succeedmg  an  inflammatory  process  of  the  posterior  cornua.  We  think  decidedly 
that  pathological  conditions  of  the  cerebral  capillaries  are  phenomena  primary  to  the 
morbid  changes  in  the  cerebral  cells  in  this  disease ;  but  it  has  not  seemed  that  the  cere- 
bral changes  were  so  invariable  and  constant  as  the  spinal ;  and  we  think  careful  obser- 
vation will  in  the  future  show  shrinking  and  atrophy  of  the  spinal  cord.  We  think  the 
changes  in  the  brain  congestive  and  hypersemic  and  not  generally  inflammatory,  and  we 
think  the  psychical  symptoms  are  immediately  dependent  upon  the  disturbances  in  the 
circulation,  which  accelerates,  impedes  or  interrupts  the  nutrient  supply  of  the  cerebral 
cells.  We  see  first,  exalted  functional  excitability  and  activity,  and  secondarily,  destruc- 
tion of  this  excitability  and  activity  with  dementia,  indicative  of  degenerative  changes 
in  the  brain-cells. 


GENERAL   PARALYSIS    OF   THE    INSANE.  ICft 

3.  That  of  special  dementia,  with  greater  stupidity  and  degradation 
than  in  other  forms,  the  control  of  muscles  diminished,  habits  dirty. 

4.  Perception  of  impressions  by  external  senses  abolished ;  insen- 
sibility to  pain;  extinction  of  functions  of  relation  and  organic  life; 
disturbance  in  circulation ;  complete  adynamic  ataxy  and  marasmus. 

Optimism  and  ambitious  ideas,  as  I  remarked  in  the  first  part  of 
this  chapter,  constitute  the  essential  mental  characteristics.  Pre- 
vious to  the  establishment  of  complete  delirium  or  delusions  there 
may  be  traced  deviations  from  healthy  mentalization,  which,  though 
faint  or  latent,  should  be  accepted  as  prodromata.  There  is  no  doubt 
that  the  gradual  evolution  of  physical  and  psychical  symptoms  cor- 
responds intimately  with  structural  alterations  in  the  nervous  centres. 
Owing  to  having  em.ployed  galvanization  of  the  cervical  sympathetic 
nerve  with  temporary  beneficial  results  in  some  cases  of  general  paral- 
ysis, the  following  question  has  presented  itself  to  my  mind :  Whether 
some  of  the  principal  changes  occurring  in  general  paralysis  may 
not.  have  their  origin  in  a  congestion  originating  in  the  ganglia  of 
the  sympathetic,  transmitted  along  the  spinal  cord,  ultimately  involv- 
ing every  tissue  within  the  cranium,  and  eventuating  simultaneously 
in  the  degeneration  of  bloodvessels,  cells,  and  nerve-tubes,  and  the 
mental  and  motor  perversions  which  distinguish  in  so  marked  a 
manner  general  paralysis  from  all  other  diseases  of  the  same  class  ? 
The  diagnostic  symptoms  of  general  paralysis,  aside  from  the  exalted 
notions,  are  difficulty  in  articulation,  with  a  trembling  of  the  tongue 
when  the  attempt  is  made  to  protrude  it  beyond  the  teeth,  often  a 
turning  to  one  side  and  a  general  inability  to  use  it  freely,  as  if  it 
were  too  large  for  the  mouth  or  too  heavy  for  use,  very  flabby,  and 
easily  indented  by  the  teeth ;  a  peculiar  dragging  of  one  of  the  feet 
or  legs ;  and  added  to  these  symptoms  will  be  found  a  heavy,  dull 
expression  of  countenance,  and  an  unusual  appearance  of  the  eyes^ 
and,  almost  invariably,  an  unequal  contraction  of  the  pupils.  It 
requires  careful  observation  to  detect  these  symptoms  in  the  early 
stages,  and  careful  treatment  may  relieve  them  temporarily  ;  but 
although  we  may  retard  the  issue  of  the  disease  by  careful  watching 
and  skilful  treatment,  it  inevitably  advances  insidiously  to  paralysis 
of  the  tongue  and  limbs  and  progressive  enfeeblement  of  the  mind. 
In  the  last  stages,  which  sometimes  last  for  years,  emaciation  suc- 
ceeds obesity.  Sometimes  there  is  intense  restlessness,  but  generally 
we  find  lethargy  of  body  as  well  as  of  mind,  this  lethargy  being  dis- 
turbed by  twitchings  or  epileptiform  convulsions.     These  often  ter- 


102  PSYCHOLOGICAL    MEDICINE. 

minate  life,  but  the  most  frequent  causes  of  death  are  sheer  exhaus- 
tion and  tubercular  disease.  With  regard  to  the  condition  of  the 
retina,  we  find  the  nerve  changes  generally  proportionate  to  the  con- 
traction and  dilatation  of  the  pupils,  the  contraction  of  the  pupil  cor- 
responding to  the  early  or  the  hyperaemic  stage,  and  the  dilatation  of 
the  pupil  to  the  white  atrophic  condition  of  the  optic  disk.  With 
regard  to  the  temperature,  I  have  always  noticed,  as  an  unvarying 
symptom,  that  there  is  always  a  higher  temperature  in  the  evening 
than  in  the  morning.  Seldom  less  than  one  degree,  and,  in  excited 
cases,  sometimes  a  difference  of  two  degrees,  and  we  may,  by  the 
thermometer,  discover  the  progress  of  the  disease  when  we  cannot  do 
it  satisfactorily  by  any  other  means.  In  sleepless  and  destructive 
cases  the  temperature  is  higher  than  it  is  in  quiet  cases.  We  may 
consider  the  average  duration  of  general  paralysis  as  about  thirteen 
months,  and  very  few  patients  live  more  than  three  years  after  the 
development  of  well-marked  symptoms. 

Dr.  Auguste  Voisin,  in  his  Tj-aite  de  la  Paralysie  Generale  des 
Alienes,  says  that  in  the  first  period  of  general  paralysis  the  principal, 
persistent,  and  most  valuable  symptoms  may  be  said  to  be : 

1.  Loss  or  diminution  of  the  sense  of  smell. 

2.  Tremulous  speech. 

3.  Fibrillary  twitchings  of  the  lips  and  the  facial  muscles. 

4.  The  pupillary  phenomena,  and 

5.  The  existence  of  fever. 

The  points  he  makes  in  regard  to  the  temperature  are : 

1.  That  in  general  paralysis  the  average  temperature  is  below  the 
normal. 

2.  That  every  eight  or  fifteen  days  it  rises  above  the  average. 

3.  That  it  stays  above  the  normal  mean  sometimes  for  only  one 
day,  sometimes  for  many  days  consecutively. 

4.  That  in  cases  in  which  this  elevation  of  temperature  continues 
for  several  days  the  elevation  of  temperature  is  always  highest  in  the 
evening. 

5.  That  the  increase  as  well  as  the  decrease  of  the  temperature  is 
sudden. 

6.  The  figure  indicating  the  temperature  is  never  high.  It  rarely 
attains  102.2°  F.,  and  more  frequently  is  between  100.04°  and 
100.4°  F. 

The  psychic  changes  are  only  an  exaggeration  of  those  of  the 
prodromal  and  intermediate  periods.    Sometimes  there  is  no  delirium, 


GENERAL    PARALYSIS    OF   THE    INSANE.  IO3 

but  only  an  enfeeblement  of  the  intellect  and  perversion  of  the  feel- 
ings, but  in  others,  and  the  majority  of  cases,  there  is  either  the  ordi- 
nary expansive  mania,  so  often  described  by  writers  on  this  disease, 
or  a  melancholic  form,  recognized  by  Falret,  Calmeil,  Pinel,  Lunier, 
Baillarger,  and  others,  and  which  is  hardly  ever  found  with  the  same 
characters  in  any  other  disorder. 

The  melancholic  type  of  mental  disorder  is  to  be  separated  in  five 
special  clinical  forms : 

a.  Melancholia  with  agitation,  which  is  distinguished  from  a  simi- 
lar state  in  other  forms  of  mental  disease  by  the  elevated  tem- 
perature. 

b.  The  melancholia  with  stupor,  the  patient  not  preserving  the 
obstinate  silence  nor  presenting  the  facial  muscular  contraction  usual 
in  such  cases  with  other  relations. 

c.  Religious  melancholia ;  a  rare  form. 

d.  Melancholia  with  ideas  of  persecution,  and  sometimes 

e..  Ideas  of  poverty,  in  which  the  patients  refuse  to  eat  because 
they  are  too  poor  or  because  food  is  too  dear. 

Voisin  also  makes  three  varieties  of  the  hypochondriac  form  of 
depression,  viz. : 

a.  The  denial  of  the  possession  of  certain  organs. 

b.  The  negation  of  existence,  and 

c.  Micromania,  or  belief  of  the  patients  that  they  are  infants  or 
children. 

The  suddenness  of  the  appearance  of  these  forms,  their  absurdity, 
and  the  variable  character  of  the  delusions,  as  in  other  forms  of 
mania,  in  paralysis,  he  thinks  sufficiently  separate  these  varieties  of 
hypochondria  from  the  non-paralytic  forms.  Voisin  recognizes  five 
varieties  of  general  paralysis  : 

1.  The  acute  and  rapid  form  (acute  periencephalitis). 

2.  The  ordinary  form,  with  grand  delirium. 

3.  The  senile  form,  characterized  by  progressive  enfeeblement  of 
the  intellect,  and  of  long  duration — six,  eight,  and  ten  years. 

4.  General  paralysis  with  all  the  characters  of  dementia.  (Voisin's 
own  discovery.) 

5.  Spinal  general  paralysis,  or  paralysis  without  alienation. 

M.  Auguste  Voisin  takes  an  altogether  more  hopeful  view  than  is 
generally  held  by  the  profession  of  the  curability  of  general  paralysis, 
even  in  confirmed  cases,  and  reports  ten  cures  on  record.  The 
best  plan  of  treatment  he  considers  to  be  exercise,  the  prohibition  of 


104  PSYCHOLOGICAL   MEDICINE. 

mental  labor,  bromides  and  cannabis  indica,  leeches  to  the  anus,  pur- 
gatives in  first  and  second  stages  of  the  disease,  and  also  sinapisms 
and  warm  foot-baths.  He  also  recommends  blistering  the  scalp  and 
nucha,  actual  cautery  along  the  spine,  and  cold  h^!^^?,  par  excellence^ 
I  have  given  a  full  description  of  M.  Voisin's  ideas  relative  to  gen- 
eral paralysis,  because  of  the  deep  interest  which  pertains  to  this 
rebellious  form  of  mental  disorder,  and  because  of  my  sincere  admira- 
tion of  his  masterly  handling  of  this  difficult  subject. 

In  closing  this  chapter  on  general  paralysis  there  are  three  ques- 
tions which  are  very  interesting  to  psychologists,  and  to  which  I 
would  invite  their  attention  : 

1.  Are  the  psychical  excitement,  exaltation,  and  delusions  of 
general  paralysis  to  be  regarded  as  the  factors  or  promoters  of  the 
physical  degeneration  ? 

2.  Are  we  entitled  to  hold,  in  remissions  in  general  paralysis, 
that  the  physical  degeneration  was  stayed  or  disappeared  during  the 
cessation  of  mental  disease,  giving  place  to  healthy  structure  ? 

3.  Are  we  entitled  to  hold,  in  general  paralysis,  that  the  resump- 
tion of  apparently  healthy  action  was  compatible  and  coexistent  with 
persistent  structural  degeneration  ? 

*  In  our  own  treatment  of  general  paralysis  we  employ  centric  galvanization,  cold 
baths,  and  we  think  highly  of  the  following  pill,  to  be  administered  every  two  hours. 
It  calms  nervous  excitability  and  supports  the  vital  powers. 

U.   Zinci  Valerianat.,     ......     .^j. 

Ext.  Belladonnse,    ......     gr.  iss. 

M.  et  ft.  pill  No.  XXX. 

At  night,  if  the  patient  is  sleepless,  we  give  the  following,  the  dose  to  be  repeated  in 
one  hour  if  the  patient  is  not  asleep. 

R.  Chloral  Hydrat., Qij. 

Sodii  Bromid.,  ......  ^j. 

Morph.  Sulph.,  ......  gr.  ^. 

Syr.  Zingib, 

Aquae,  aa,        .         .         .         .         .         .         .  i"^]. 

M.  et  ft.  sol.     S.  Tablespoonful  at  bedtime. 


IDIOCY— DEMENTIA — FOLIE    RAISONNANTE.  lof 

CHAPTER  VII. 

IDIOCY DEMENTIA — FOLIE    RAISONNANTE. 

(Syn. — Moral  or  Affective  Insanity.^ 

An  idiot,  according  to  Lord  Coke's  definition,  is  "  one  who  from 
his  nativity,  by  a  perpetual  infirmity,  is  7ion  compos  mentis^ 

Idiocy  is  a  condition  in  which  the  intellectual  faculties  have  never 
been  developed  sufficiently  to  enable  the  idiot  to  acquire  such  an 
amount  of  knowledge  as  persons  of  his  own  age,  and  placed  in 
similar  circumstances  with  himself,  are  capable  of  receiving.  This 
latter  is  essentially  Esquirol's  definition  of  idiocy.  The  progress  of 
modern  science  is  such,  however,  that  we  no  longer  believe  that  the 
faculties  of  the  idiot  must  remain  stationary.  In  idiocy  there  is  an 
impairment  of  the  functions  of  organic  and  animal  life.  Any  of  the 
special  senses  may  be  more  or  less  involved.  There  are  various  de- 
grees of  idiocy,  from  the  idiot  who  exhibits  nothing  beyond  reflex 
action  to  those  whose  ideas  produce  some  intellectual  operations  and 
consequent  will.  In  deciding  whether  a  child  is  idiotic  we  must  ex- 
amine the  special  senses,  sight,  hearing,  smell  and  taste,  the  general 
aspect  of  the  child,  the  form  of  the  head,  whether  microcephalic  or 
hydrocephalic.  Most  cases  of  idiocy  present  more  or  less  malforma- 
tion of  the  skull.  The  ears  should  be  examined,  as  in  idiocy  they 
are  large  and  ill-formed.  The  eyes  in  idiocy  have  a  vacant  stare  and 
do  not  follow  objects  held  before  them.  The  hand  of  an  idiotic  child 
will  not  grasp  your  fingers  properly.  The  grasp  is  feeble  and  pow- 
erless and  the  hands  are  cold  and  blue.  If  old  enough  to  talk,  notice 
the  character  of  the  vocal  sounds. 

In  the  treatment  of  idiocy  we  must  rescue  the  child  from  a  soli- 
tary life  and  surround  him  by  influences  calculated  to  make  existence 
pleasant.  "  We  must  attain  to  the  happy  combination,"  says  an 
eminent  authority,  "  of  medical,  physical,  moral,  and  intellectual 
treatment."  The  highest  possible  health  is  the  great  desideratum. 
The  dietary  must  contain  a  fair  supply  of  nitrogenous  elements,  and 
at  the  same  time  be  rich  in  oleaginous  and  phosphatic  substances. 
The  daily  use  of  sponge  baths  is  of  paramount  importance,  as  there 
is  a  peculiar  exhalation  from  the  skin  of  imbeciles.  As  regards 
physical  training  the  attenuated  muscles  should  be  carefully  and 
fully  exercised,  to  obviate  the  simple  automatic  movements  so  com- 
mon to  the  imbecile  and  idiot.     The  moral  education  must  inculcate 


I06  PSYCHOLOGICAL    MEDICINE. 

obedience,  although  corporeal  punishment  should  never  be  resorted 
to.  The  idiot  should  be  made  to  understand  that  right  is  productive 
of  pleasure,  and  wrong  followed  by  the  reverse.  Study  the  peculiari- 
ties of  the  patient,  and  you  can  then  control  him  morally.  The  in- 
tellectual training  must  teach  the  idiot  the  qualities,  form  and  rela- 
tion of  objects,  by  the  sense  of  touch;  color,  size  and  shape  by  the 
sense  of  sight,  and  the  varieties  of  sound  by  the  ear.  The  idiot  must 
be  taught  habits  of  neatness.  Imperfect  speech  is  best  overcome  by 
a  series  of  tongue  gymnastics.  We  must  provide  varied  amuse- 
ments, especially  of  an  object-teaching  character,  and  we  can  get 
good  results  by  patience  and  perseverance.* 

Dejiieiitia. — The  chief  moral  cause  of  acute  or  primary  dementia 
is  mental  inanition  or  monotony  of  thought  or  feeling.  If  our  men- 
tal food  is  not  varied  it  ceases  to  nourish  us,  and  we  pine  into  demen- 
tia. Acute  dementia  follows  exhausting  disease  frequently,  and  right 
here  let  me  say  that  at  such  times,  to  prevent  brain  wasting,  the  chlo- 
rophosphide  of  arsenic  (Routh's  formula)  is  invaluable,  in  doses  of 
five  drops  in  water,  gradually  decreased  to  two  drops,  three  times  a  day, 
and  persisted  in  for  months.  Acute  dementia-  begins  in  one  of  two 
ways,  either  gradually,  by  imperceptible  encroachments,  or  by  maniacal 
excitement.  The  acme  of  dementia  is  a  mental  state  of  profound  stu- 
pidity. The  pathology  of  dementia  is  generally  a  venous  congestion 
which  affects  the  whole  encephalon,  but  the  frontal  and  parietal  lobes 
are  chiefly  implicated.  The  vessels  are  cedematous  from  the  accus- 
tomed want  of  tone  ;  this  causes  pressure  on  the  brain,  and  if  of  long 
continuance  atrophy  results.  Acute  dementia,  therefore,  is  a  disease 
of  venous  congestion.f 

*  J.  Langdon  Down  very  truly  says  of  idiocy  that  the  lesion  is  not  only  a  psychical  one, 
but  profoundly  affects  the  physical  and  frequently  the  moral  life.  The  stature  is  less  than 
normal,  with  great  tendency  to  assume  a  stooping  posture.  The  circulatory  system  is 
weak,  the  lungs  liable  to  inflammatory  attacks,  the  gastro-intestinal  tract  liable  to  derange- 
ment, the  sexual  functions  often  abnormal,  the  motor  functions  are  abnormal ;  there  is 
diminished  sensibility,  speech  is  defective,  sight  defective,  sense  of  smell  is  lessened,  and 
no  discrimination  of  odors  ;  the  faculties  of  observation  and  attention  are  limited ;  there  is 
very  little  imagination  or  power  of  abstract  thought.  We  may  classify  it  into  I.  Congeni- 
tal; 2.  Developmental ;  and  3.  Accidental  idiocy.  The  first  class  exhibit  signs  of  defec- 
tive mental  power  at  birth.  The  second  class  manifest  an  average  intelligence  through 
infancy,  but  break  down  during  one  of  the  developmental  crises,  these  being  the  first  den- 
tition, the  second  dentition,  or  at  puberty.  The  third  class  are  born  with  a  normal  nervous 
system  free  from  defect,  but  a  fall,  a  fright,  epilepsy,  the  sequelae  of  measles,  scarlet  fever, 
meningitis,  etc.,  may  lead  to  a  mental  break  down  and  accideiitalx&xozy. 

J  Primary  or  acute  dementia  may  be  accompanied  by  the  most  profound  vacuity,  accord- 
ing to  Blandford,  and  abeyance  of  all  the  mental  faculties,  and  yet  yield  to  treatment. 


IDIOCY — DEMENTIA — FOLIE   RAISONNANTE.  lOf 

Folie  Raisonnante,  Synon.,  Moral  or  Emotional  Insanity  Proper. — 
There  are  equivocal  states  of  mental  alienation  or  so-called  reason- 
ing insanity  (folie  raisonnante),  which  may  exist  alone  and  disappear 
before  the  appearance  of  the  ordinary  attack.  The  slightest  form  of 
folie  raisonnante  is  that  in  which  the  patient  is  more  or  less  aware  of 
the  morbid  conception.  If  he  conceals  it  we  are  unable  to  detect  it; 
if  he  acknowledges  it,  it  is  in  such  a  way  that  we  hesitate  to  believe 
him  insane.  A  more  decided  form  is  that  in  which  the  patient  is 
just  conscious  of  his  insanity.  He  accepts  the  insane  notion,  but 
understands  that  it  is  for  his  interest  to  hide  it.  Still  farther 
along  the  same  patient  does  not  conceal  his  delusion.  Those  pa- 
tients who  remain  very  long  in  an  uncertain  mental  condition  are 
those  who  most  frequently  manifest  abnormal  forms  of  insanity. 
There  are  prolonged  lucid  intervals  in  every  kind  of  mental  aliena- 
tion. Between  reason  and  confirmed  insanity  there  is  every  shade 
of  reasoning  power. 

Bucknill  and  Tuke  say  in  speaking  of  these  cases  that  "  they  are 
mainly  of  a  destructive  character,  and  may  be  distinguished  from 
emotional  disorder  of  a  melancholy  and  exalted  character  by  the 
term  '  emotional  insanity  proper,'  or  moral  insanity." 

There  are  congenital  cases  of  defect  or  disease  of  the  moral  facul- 
ties, and  others  in  which  this  condition  of  mind  comes  on  or  is  first 
exhibited  in  adult  life.  Respecting  the  former  class  of  cases  Buck- 
nill and  Tuke  say :  "  The  most  striking  feature  of  insanity  in  gen- 
eral, and  the  strongest  proof  of  the  presence  of  any  of  its  forms,  is 
the  change  which  takes  place  in  the  individual's  character  and  habits." 
To  cases  of  congenital  deficiency  of  the  intellect,  however,  whether 
altogether  idiotic  or  only  partially  imbecile,  it  is  at  once  manifest 
that  this  test  does  not  and  cannot  apply.  In  such  instances  the  natu- 
ral character  is  itself  in  an  abnormal  condition,  and  ceases  to  be  the 
standard  of  health.     This  observation  applies  with  peculiar  force  to 

leaving  the  patient  sane.  The  patients  are  young  persons — boys  and  girls.  There  is  a 
collapse  of  all  mental  power;  the  face  is  vacant,  with  a  fatuous  grin,  and  often  the  saUva 
dribbles  continuously  and  the  patient  has  to  be  tended  like  a  baby ;  the  hands  and  feet 
are  blue  with  cold ;  the  tongue  is  pale  and  flabby,  and  the  pupils  are  dilated.  Dementia 
is  more  often  secondary ;  that  is,  occurring  after  mania,  melancholia,  monomania,  than 
primary.  We  have  in  primary  dementia  a  rapid  suspension  of  the  intellectual,  moral  and 
instinctive  faculties — a  state  which  is  curable.  In  treatment  abundant  nutrition,  stimulants, 
warmth,  mild  exercise,  cold  baths  or  the  shower  bath,  the  patient  standing  in  warm  water, 
central  galvanization,  and  iron  and  quinine,  or  a  combination  of  iron,  phosphorus,  zinc, 
and  strychnia,  are  all  indicated  to  restore  lost  nerve  tone.  Ordinary  dementia  is  very  in- 
curable. 


I08  PSYCHOLOGICAL   MEDICINE. 

the  matter  now  under  consideration.  If  there  ever  be,  congenitally, 
a  condition  of  the  moral  sense  analogous  to  imbecility,  it  is  impossi- 
ble to  apply,  in  such  instances,  the  test  referred  to — a  test  which  is 
alone  applicable  to  mental  disease  when  acquired.  We  have  seen 
several  well-marked  examples  of  lunatics,  who,  on  arriving  at  man- 
hood, were  placed  under  restraint,  because  age  brought  with  it  a  cer- 
tain legal  responsibility,  the  absence  of  which,  in  early  life,  rendered 
the  patient's  friends  willing  to  content  themselves  with  their  own 
sur\'eillance.  In  such  cases,  parents  assert  that  the  child,  the  boy, 
the  young  man,  alike  presented  the  symptoms  of  an  inert  moral  na- 
ture, and  of  an  activity  of  the  animal  propensities,  over  which  threats, 
rewards  or  punishments  exercised  a  very  trifling  control. 

There  was  a  patient  formerly  at  the  Richmond  Lunatic  Asylum, 
Dublin,  whose  case  illustrates  this  class.  We  are  informed  that  "  he 
exhibited  a  total  want  of  moral  feeling  and  principle,  yet  possessed 
considerable  intelligence,  ingenuity  and  plausibilit}^"  "  He  has 
never,"  says  Dr.  Crawford,  "been  different  from  what  he  now  is;  he 
has  never  evinced  the  slightest  mental  incoherence  on  any  one  point, 
nor  any  kind  of  hallucination.  He  appears,  however,  so  utterly  cal- 
lous with  regard  to  every  moral  principle  and  feeling,  so  thoroughly 
unconscious  of  ever  having  done  anything  wrong,  so  completely  des- 
titute of  all  sense  of  shame  or  remorse  when  reproved  for  his  vices 
or  crimes,  and  has  proved  himself  so  utterly  incorrigible  throughout 
life,  that  it  is  almost  certain  that  any  jury  before  whom  he  might  be 
brought  would  satisfy  their  doubts  by  returning  him  insane."  A 
very  remarkable,  and  in  some  respects  analogous,  case  is  reported  in 
the  American  Joiirnal  of  Insanity  (October,  1846).  A  girl,  eighteen 
years  of  age,  guilty  of  arson,  is  represented  to  have  been  quite  des- 
titute of  the  moral  feelings.  "  She  possessed  quick  perceptions,  good 
reflective  capacity,  and  a  large  share  of  ideality,  etc. ;  but  no  human 
kindness  had  she,  nothing  human  indeed,  but  her  form."  She  is 
stated  to  have  resembled  a  serpent  in  her  movements.  "  Her  skin  was 
cold — circulation  very  slow;  her  skin  was  spotted  like  a  common 
species  of  snake."  Dr.  Davey  has  expressed  himself  very  decidedly 
in  favor  of  the  union  of  moral  idiocy  with  intellectual  ability,  in  an 
interesting  paper  in  the  Associatioti  Med.  Journal  (September  13th, 
1856) ;  and  although  we  hesitate  to  admit  what  can  properly  be  called 
moral  idiocy  apart  from  more  or  less  lesion  of  the  intellect,  we  fully 
grant  that  there  may  occasionally  be  good  intellectual  abilities  in  as- 


IDIOCY DEMENTIA FOLIE    RAISONNANTE. 


[O^ 


sociation  with  congenitally  feeble  moral  powers  and  volition  (a  moral 
insensibility),  and  therefore  a  proportionate  irresponsibility. 

We  may  mention  the  case  of  a  patient  admitted  into  an  asylum  at 
the  age  of  seventeen,  laboring  under  moral  insanity  and  epilepsy. 
He  possessed  decided  intellectual  vigor,  united  with  an  exceedingly 
obtuse  perception  of  moral  responsibility.  His  father  stated  that  his 
character  had  been  the  same  "  from  the  cradle."  At  nine  years  of 
age  he  endangered  the  life  of  a  little  boy,  his  play-fellow;  subse- 
quently at  school  he  was  characterized  by  similar  mental  qualities, 
learning  more  quickly  than  other  boys,  yet  committing  many  acts  of 
violence.  He  was,  consequently,  obliged  to  leave  several  schools. 
We  know  of  another  well-marked  case  of  peculiarity  in  the  temper 
and  moral  disposition,  manifested  from  the  earliest  infancy,  in  which 
the  intellectual  faculties  are  not  only  equal  to  but  above  the  average. 
The  disease  or  defect  was  hereditary.  The  patient  has  been  in  an 
asylum  for  years.  The  same  author  speaks  thus  of  the  condition 
of  mind  (moral  or  affective  insanity),  when  first  exhibited  in  adult 
life:  "  Here  the  standard  of  mental  health  may  justly  be  sought  for 
in  the  natural  and  habitual  character  of  the  patient."  This  it  is 
which  is  now  altered,  and  the  symptoms  by  which  it  is  rendered 
manifest  may  next  be  considered.  Usually  the  change  in  the  feelings 
and  conduct  of  the  patient  is  gradual.  Frequently,  he  is  more  ab- 
sorbed and  reserved,  and  on  any  provocation,  however  slight,  is  un- 
reasonably irritated.  He  becomes  suspicious,  liable  to  attribute  false 
motives  to  his  friends  and  others,  and  to  cast  ungenerous  reflections 
upon  his  nearest  relatives.  The  husband  suspects  the  fidelity  of  the 
wife,  the  wife  that  of  the  husband,  without  the  slightest  foundation. 
The  patient  is  observed  by  strangers  to  be  morose,  and  as  the  cloud 
gathers  his  acquaintances  become  conscious  that  he  is  somehow  or 
other  an  altered  man,  without  knowing  why,  and  very  probably  with- 
out once  supposing  the  man  to  have  become  insane. 

At  last  the  storm  bursts,  and  some  act  is  committed  of  an  outra- 
geous character.  He  is  then  regarded  as  either  insane  or  criminal : 
the  former,  probably,  if  the  act  does  not  make  him  decidedly  amena- 
ble to  the  laws  of  his  country,  and  his  destination  is  the  asylum ;  the 
latter,  most  probably,  if  the  act  has  been  homicidal,  and  he  is  con- 
signed to  the  executioner. 

In  other  cases  an  individual  has  been  subjected  to  overexertion  of 
mind,  his  powers  overtasked,  or  his  feelings  put  upon  the  stretch  in 
consequence  of  anxiety  or  unaccustomed  responsibility.     He  then 


no  PSYCHOLOGICAL   MEDICINE, 

finds  himself  susceptible  to  the  slightest  mental  emotion,  loses  his 
sleep  and  rest,  is  conscious  of  more  or  less  uneasiness  about  the  head, 
a  sense  of  tension  and  dull,  aching  pain,  is  probably  troubled  with 
palpitation  of  the  heart,  and  finds  himself  unequal  to  the  discharge  of 
his  usual  duties.  His  digestive  organs  are  also  often  disordered,  his 
appetite  uncertain,  the  secretions  depraved.  In  addition  to  all  this, 
he  may  be  distressed  by  certain  impulses  and  tendencies  which  are 
alike  repugnant  to  his  reason  and  to  the  dictates  of  his  moral  nature. 
Often  the  impulse  "  is  to  do  violence  to  himself  or  others,  or  simply 
to  break  glass  or  articles  of  furniture."  Pinel  was  the  first  to  call 
these  cases  "  reasoning  madness,"  while  Pritchard  preferred  the  term 
"  moral  insanity."  Ray  tells  us  that  "  the  affective  as  well  as  the 
intellectual  faculties  are  subject  to  derangement." 

There  are  cases  where  there  is  the  presence  of  homicidal  impulse 
and  also  cases  of  suicidal  impulse,  without  other  symptoms  of  insan- 
ity. I  think  a  close  examination  would  reveal  an  insane  taint  in  the 
family  history  could  it  be  brought  to  light. 

Dr.  Blandford,  of  England,  says  :  "  Under  the  names  of  moral  in- 
sanity, emotional  insanity,  impulsive  insanity,  affective  insanity,  has 
been  described  the  disorder  of  certain  patients,  which  is  manifested 
by  insane  actions  and  conduct  rather  than  by  insane  ideas,  delusions, 
or  hallucinations.  Such  persons  are  sometimes  said  to  be  of  whole 
and  perfect  intellect,  though  unsound  in  the  moral  and  emotional 
part  of  their  brain.  They  come  under  the  notice  of  medical  men  not 
so  much  for  purposes  of  treatment  as  for  diagnosis.  Their  conduct 
being  chiefly  displayed  in  foolish  or  violent  acts,  they  require  to  be 
restrained,  and  the  question  arises :  Is  this  conduct  badness  or  mad- 
ness ?     Are  they  responsible  for  it  or  not?" 

There  is  in  all  the  cases  of  this  form  of  insanity  that  the  author  has 
met  with  a  total  absence  of  delusion,  and  this  may,  perhaps,  be  said 
to  be  the  great  diagnostic  mark  of  reasoning  mania,  or  moral  or 
affective  insanity,  whichever  we  may  please  to  term  it.  There  is  in 
these  cases  an  entire  change  of  character  and  habits,  evinced  by  ex- 
traordinary acts  and  conduct.  There  are  false  assertions  and  false 
views  concerning  the  best  friends  and  relatives.  The  approach  of 
this  form  of  insanity  is  not  sudden,  but  rather  gradual  and  impercep- 
tible. The  strange  character  of  the  acts  is  not  at  first  so  marked 
as  it  is  afterwards.  It  generally  takes  some  time  before  the  patient's 
friends  can  convince  themselves  that  such  conduct  is  the  result 
of  disease,  and  many  will  look  upon  such  an  insane  person's  acts 


IDIOCY — DEMENTIA FOLIE   RAFSONNANTE.  Ill 

as  the  signs  of  depravity.  After  a  time  the  insanity  becomes  well- 
marked,  and  overt  acts  are  committed  which  leave  no  difficulty  in 
making  a  diagnosis.  False  and  apparently  wicked  assertions  con- 
cerning the  nearest  relatives,  or  plots  to  annoy,  may  constitute  almost 
the  only  symptom,  at  times,  of  this  form  of  insanity  which  the  public 
can  see  or  hear  of,  particularly  if  the  nearest  relatives  carefully  con- 
ceal from  the  world  all  outrageous  conduct  which  is  shown  at  home. 
Such  patients  deceive  the  public  by  their  plausibility  and  their  ready 
excuses  for  their  conduct.  Dr.  Blandford  very  truly  says  :  "  When 
we  can  ascertain  that  the  condition  of  things  is  something  which  has 
come  over  the  patient,  being  formerly  absent,  and  that  a  man  is 
altogether  changed,  we  may  suspect  insanity."  These  patients  are 
very  acute  and  cunning,  and  most  unmitigated  liars.  There  may 
sometimes  be  in  the  history  of  these  cases  a  period,  though  short, 
of  acute  mania  or  acute  melancholia.  This  may  also  be  a  precursor 
of  a  marked  insanity  with  delusions  and  hallucinations.  In  this  vari- 
ety of  insanity  a  man  may  squander  all  his  property  or  he  may  be- 
come a  dipsomaniac.  This  form  sometimes  constitutes  one  period 
of  circular  insanity,  where  periods  of  depression  alternate  with  those 
of  excitement,  with  exaggerated  conduct  and  absurd  acts. 

The  responsibility  of  the  class  who  have  been  from  birth  odd  and 
peculiar,  and  who  seem  incapable  of  acting  and  behaving  like  other 
people,  is  sometimes  difficult  to  estimate.  They  have  a  congenital 
moral  defect ;  they  never  tell  the  truth ;  they  are,  so  to  speak,  moral 
imbeciles,  and  it  is  very  hard  to  say  just  how  far  they  are  responsible. 
Guiteau  was  just  such  a  case.  They  are  generally  the  offspring  of 
parents  tainted  with  insanity. 

C.  H.  Hughes,  M.D.,  St.  Louis,  Missouri,  says,  respecting  moral 
(affective)  insanity : 

Notable  instances  of  the  subversion  of  mind,  without  accompaniment  of  mental  per- 
version, are  found  in  those  cases  of  gangliopathy  which  proceed  to  the  extent  of  fainting, 
epilepsia,  chorea,  etc.,  in  which  either  volition  or  both  the  will  and  consciousness  are 
subverted.  The  ganglionic  (visceral)  origin  of  certain  forms  of  hypochondria,  melan- 
cholia, and  hystero-mania  has  been  admitted  since  the  time  of  Hippocrates.  Morbid 
states  of  the  reproductive  system  have  long  been  deemed  sufficient  sources  of  certain 
forms  of  mental  derangement,  in  which  the  feelings  rather  than  the  reasoning  processes 
are  disordered. 

It  is  conceded  that  kleptomania,  pyromania,  dipsomania,  homicidal  and  suicidal  im- 
pulses, and  the  morbid  displays  of  pregnant  women,  and  the  mind  disorders  connected 
with  the  critical  periods  of  woman's  life,  may  have  their  starting-point  in  uterine  disorder, 
even  with  more  unanimity  and  certainty  than  puerperal  mania,  for  the  latter  is  often  as 
much  an  insanity  of  general  hsemic  and  neuric  exhaustion— anaemia  and  shock— as  of 


112  PSYCHOLOGICAL    MEDICINE. 

reflex  irritation.  And,  if  reflex  insanity  be  conceded,  the  possibility  of  moral  insanity 
must  be  admitted,  for  the  concession  acknowledges  the  varj'ing  shades  of  mental  involve- 
ment, depending  upon  the  degree  and  source  of  the  reflected  irritation,  from  the  insane 
longings  and  freaks  of  pregnancy  to  the  infanticidal  and  other  morbid  impulses  of  post- 
partum cerebrasthenia.  To  concede  the  possibility  of  a  homicidal  or  other  morbid 
impulse  not  founded  in  delusion  (and  psychiatry  furnishes  abundant  proofs  of  such 
impulses),  is  to  admit  the  basis  fact  of  moral  insanity  as  it  is  clinically  observable,  namely, 
insanity  not  the  result  of  reason  pei*verted  by  disease.* 

\Vhen  ganglionic  disease  is  great  and  the  morbid  consequences  profound  enough  to 
involve  the  intellectual  faculties  in  marked  disorder,  those  who  deny  the  possibility  of 
insanity  existing  without  appreciable  lesion  of  the  intellect,  now  willingly  admit  the  exist- 
ence of  mental  disease,  and  wiwittiugly,  in  those  minor  degrees  of  eccentric  irritation 
connected  with  the  period  of  utero-gestation  and  manifested  in  peevishness,  and  insa- 
tiable longings  and  changes  of  temper,  they  charitably  concede  that  the  patient  is  to  be 
excused  for  not  putting  as  complete  a  rein  upon  the  display  of  eccentric  feeling  and 
action  as  would  be  considered  the  proper  thing  in  one  not  enceinte.  The  intellect  may 
appear  intact  or  coexistent  with  a  minor  degree  of  moral  or  emotional  perversion,  and 
the  perverted  moral  feeling  excused  or  extenuated,  if  indulged  ;  yet,  if  we  pass  a  few 
steps  further  and  venture  to  saj'  that  a  seemingly  resistless  impulse,  to  which  the  will 
yields  while  the  intellect  disapproves,  is  insanity,  then  their  theoretical  conception  of  the 
unity  of  mind — it  being  impossible  for  them  to  understand  how  emotion,  volition,  and 
thought  can  be  separate — leads  to  the  rejection  of  one  of  the  most  demonstrable  facts  in 
practical  psychiatry,  as  well  as  one  of  the  most  demonstrable  facts  in  our  every-day  inter- 
course with  minds  that  are  not  insane.  Persons  in  the  best  of  health  are  constantly  acting 
from  impulse,  prejudice,  or  passion,  conforming  to  society's  usages  and  the  dictates  of 
fashion  or  feeling  without  sufficient  thought. 

The  emotions  and  the  intellect  are  not  twin-born,  though  they  mutually  influence  each 
other.  They  do  not  always  go  hand-in-hand  or  dwell  harmoniously,  though  tenanted 
together  in  the  brain.  In  good  cerebral  organizations  they  are  often  at  war  with  each 
other.  The  things  which  even  sane  men  ought  not  to  do  they  often  do,  and  those  they 
ought  to  do  they  sometimes  do  not. 

The  Apostle  Paul  confesses  this  of  himself.  If  a  saint  can  concede  this  much  of  a 
healthy  mind,  a  sinner  can  do  no  less  for  the  victim  of  disease.  Paul  was  a  good  psy- 
chologist, and  discerned,  though  unconscious  of  their  physiological  foundation,  the  gan- 
glionic source  of  certain  encephalic  states.  He  was  "  constantly  at  war  with  his  mem- 
bers."    When  he  "  would  do  good,  evil  was  present  with  him." 

■=^  Tilt  saw  a  case  where  pressure  upon  an  inflamed  ovary  excited  epileptic  fits.  I  have 
seen  a  vaginal  injection  cause  a  maniacal  paroxysm,  some  of  the  injected  fluid  having 
passed  up  into  the  uterine  cavity.  Sir  Benjamin  Brodie  brought  on  a  fit  of  chorea  by 
gentle  pressure  over  the  stomach,  and  the  effect  of  a  smart  blow  in  producing  faintness  is 
so  well  known  to  the  prize-ring  that  it  is  considered  foul  to  hit  below  the- belt.  Even 
death  has  resulted  from  violence  done  to  the  semilunar  ganglia.  But  these  eff"ects  are 
not  more  singular  than  the  irritation  of  dentition,  or  worms,  or  undigested  substances  in 
the  alimentary  canal  causing  infantile  convulsions;  the  effect  of  a  fistula  in  causing  mel- 
ancholia with  impulse  to  suicide — passing  away  after  a  successful  operation ;  the  many 
eccentric  sources  of  epilepsia,  tetanus,  cerebral  irritation,  hypersemia,  etc. 

Tait  excises  an  ovary  and  cures  an  epilepsv ;  Charcot  compresses  one ;  and  Kussmaul 
a  testicle,  causing  reflex  hystero-epilepsy ;  and  the  temporary  subversion  of  mind  from 
wound  of  testicle  was  well  known  before  Charcot,  Kussmaul,  Tait,  Brodie,  or  Tilt  were 
known  to  fame. 


IDIOCY — DEMENTIA FOLIE    RAISONNANTE.  IIJ 

I  commend  St.  Paul  as  a  psychologist  to  certain  of  our  confreres.  May  the  convincing 
light  of  truth  shine  upon  them  as  it  did  upon  the  persecutor  of  the  proto-martyr  on  his 
way  to  Damascus,  and  by  way  of  contrition  for  the  wrong  they  have  done  and  may  yet 
do  that  least  commiserated  of  all  the  mentally  afflicted, — the  emotional,  the  impulsive, 
and  the  morally  insane, — may  they  speedily  make  amends  by  renouncing  their  heresies 
and,  embracing  the  true  faith,  become  followers  of  the  faithful  Rush,  Pinel,  Prichard, 
Maudsley,  Bucknill,  Tuke,  and  Ray. 

Stephen  had  been  stoned,  it  is  true,  but  there  still  remained  others  to  be  saved.  Many 
an  honest  Saul  in  our  ranks,  consenting  to  this  wrong,  remains  to  be  converted.  If  there 
be  any  who,  in  perfect  health,  has  not  yielded  to  the  dominion  of  impulse,  emotion, 
or  passion,  let  him  cast  the  first  stone  at  the  victim  of  mental  disease,  whose  intellect, 
while  it  does  not  restrain,  yet  seems  not  touched  by  the  morbid  process  which  has  de- 
ranged the  affections,  the  emotions,  and  the  will. 

Insanity  of  the  emotions,  propensities,  and  passions,  in  which  the  intellect,  if  at  all  dis- 
ordered, is  not  app7'eciably  so,  or  only  7Jiomentarily  so  by  being  in  abeyance  or  unable, 
through  some  want  of  connection  of  the  will  or  controlling  power  of  the  latter  over  the 
impulses  and  passions,  is  a  fact,  however  it  tnay  clash  with  theories  of  the  so-called  unity 
of  mind.  It  is  a  fact  as  much  so  as  ecstasy  or  hypnotism,  somnambulism  or  dreaming, 
which  are  not  completely  harmonious  and  united  actions  of  all  the  mental  powers.  As 
much  a  fact  as  prejudiced,  or  biased,  or  unconscious  cerebration  in  the  healthy,  working 
state  of  mind.  As  much  a  fact  as  the  many  varieties  of  aphasia  without  intellectual 
impairment,  which  the  great  Trousseau  rejected,  because  he  was  biased  in  judgment  by 
the  dominant  theory  of  Condillac  and  Warburton,  that  the  mind  could  only  think  in 
speech.  As  much  a  fact  as  certain  illusions  or  hallucinations  in  which  the  intellect  does 
not  concur,  though  during  the  formation  stage  of  these  mental  spectra  the  reason  may  be 
in  momentary  abeyance.  We  should  recognize  the  fact,  though  in  so  doing  we  may  have 
to  mend  our  theories  or  even  abandon  them.  We  should  never  whittle  down  facts  to 
preconceived  metaphysical  notions. 

All  observation  of  the  varying  degrees  of  emotional,  impulsive,  and  intellectual  life  in 
different  persons  and  in  the  same  person  at  different  ages  of  life  attest  the  possibility  of 
disorder  of  the  emotions,  propensities,  or  passions,  without  more  appreciable  intellectual 
lesion  than  we  see  in  persons  who  are  regarded  as  right-minded. 

Though  insanity  is  marked  generally  by  change  of  character,  that  change  is  seldom 
manifested  in  augmenting  the  power  of  the  intellect  and  the  will  over  the  emotions  or 
passions.  On  the  contrary,  the  latter  often  subvert  the  former.  Usually  the  disease, 
beginning  with  moral  or  emotional  perversion,  gradually  involves  or  undermines  the  rea- 
son and  judgment.  It  is  thus  that,  in  the  early  stages,  moral,  emotional,  and  impulsive 
disorder  is  mainly  divorced  from  the  intellect  (if  the  two  are  ever  then  truly  wedded), 
and  what  begins  with  an  insanity  of  the  feelings,  propensities,  or  passions,  usually  goes 
on  (if  not  arrested  by  timely  medical  interference)  to  the  graver  forms  of  more  general 
mental  involvement.  These  cases  may  even  pass,  if  not  cured,  into  the  stages  of  delu- 
sion and  dementia,  a  fact  which  has  led  some  writers  to  doubt  their  existence  unless 
associated  with  intellectual  involvement,  but  which  really  proves  the  kinship  of  these 
contested  varieties  of  mental  derangement,  even  where  neither  delusion  or  other  intel- 
lectual lesion  appears,  with  universally  recognized  forms  of  insanity,  just  as  the  insane 
heredity  of  moral  mania  often  establishes  in  our  mind  the  fact  of  insanity  as  contradis- 
tinguished from  uncomplicated  vice  when  we  are  in  doubt. 

Men  in  their  sanest  states  are  often  more  influenced  by  their  feelings,  prejudices,  and 
passions  than  by  their  judgments.  Insanity  generally  expresses  itself  more  in  action  than 
in  speech.     The  restlessness  and  constant  muscular  activity  of  many  lunatics  is  not  always 


114  PSYCHOLOGICAL   MEDICINE. 

the  expression  of  disordered  intellection  so  much  as  it  is  an  accompaniment  simply  of 
morbid  feeling  or  irritation  of  psycho-motor  centres,  and  sometimes  the  acts  of  the  insane, 
if  their  after  confessions  in  seemingly  lucid  intervals  may  be  taken  as  even  approximately 
true,  are  not  infrequently  independent  of  both  conscious  thought  and  feeling.  They 
appear  often  as  blind  freaks  of  disease  or  mental  caprice,  in  which  the  highest  intellectual 
centres  seem  only  unconsciously  involved. 

That  vigorous  thinker,  John  Locke,  who  was  not  a  mere  surface  observer,  though  he 
looked  at  insanity  rather  too  superficially  for  a  practical  alienist,  was  led  to  the  conclu- 
sion— not  strictly  true,  but  not  altogether  erroneous — that  the  insane  did  not  so  much 
"  appear  to  have  lost  the  faculty  of  reasoning,  but,  having  joined  together  some  ideas 
very  wrongly,  they  mistake  them  for  truths,  and  they  err  as  men  do  who  argue  right  from 
wrong  principles,  for  by  the  violence  of  their  imaginations — having  taken  their  fancies 
for  realities — they  make  right  deductions  from  them.  Thus  you  shall  find  a  distracted 
man  fancying  himself  a  king,  with  a  right  inference  requiring  suitable  attendance,  respect, 
and  obedience ;  others,  who  have  thought  themselves  made  of  glass,  have  used  the  cau- 
tion necessary  to  preserve  such  brittle  bodies.  Hence  it  comes  to  pass  that  a  man  who 
is  very  sober  and  of  a  right  understanding  in  all  other  things  may,  in  one  particular,  be 
as  frantic  as  any  in  Bedlam  if  either  by  any  sudden,  very  strong  impression,  or  long  fixing 
his  fancy  upon  one  sort  of  thoughts,  incoherent  ideas  have  been  cemented  so  powerfully 
as  to  remain  united."  Locke  here  has  reference  to  the  deluded  or  delusional  insane,  and 
is  only  in  part  correct,  for  the  insane  do  often  both  reason  illogically  and  incoherently 
and  establish  wrong  premises,  from  which  their  reasoning  proceeds.  Doubtless  the  cor- 
rect reasoning  manifested  sometimes  in  the  affective  insanities  contributed  to  the  forma- 
tion of  his  only  partly  correct  opinion,  for  in  the  next  sentence  he  says,  "  There  are 
degrees  of  madness  as  there  are  of  folly — the  disorderly  jumbling  of  ideas  together  is  in 
some  more,  some  less,"  and  in  some  (he  might  have  concluded,  had  he  been  as  familiar 
with  the  insane  as  they  should  be  who  aspire  to  correct  notions  respecting  them)  there 
seems  to  be  no  appreciable  lesion  of  the  reasoning  faculties. 

Locke's  idea  of  insanity  was  that  it  must  always  be  intellectual  aberration,  and  yet  his 
observation  taught  him,  despite  his  philosophical  bias, — a  bias  in  which  many  mental 
philosophers  of  the  purely  psychical  school  still  share, — that  7nany  h^cnatics  reasoned  well. 
It  never  occurred  to  him  to  deny  the  existence  of  insanity  in  such,  but  to  assume  that 
they  joined  some  ideas  wrongly  together. 

With  reference  to  another  observation  of  Locke's,  viz.,  "  that  reverence  gives  beauty 
and  prejudice  deformity  to  our  opinions,"  it  may  assuredly  be  said  with  equal  truth  that 
intellectual  processes  in  both  the  sane  and  the  insane  are  incited  to  action  and  influenced 
by  moral  or  other  emotions,  excited  either  by  example  of  others  or  by  disease. 

Those  who  deny  the  existence  of  moral  insanity  insist  that  there  always  exists  a  certain 
degree  of  intellectual  acquiescence  that  entitles  it  to  be  termed  intellectual  insanity, 
though  that  intellectual  perversion  may  be  and  often  is  no  greater  than  that  which  is  ■ 
found  in  the  naturally  immoral  and  depraved ;  but,  if  one  concede  this,  there  yet  remain 
cases  of  moral  and  emotional  disease  where  the  intellect  not  only  does  not  acquiesce  in, 
but  actually  discountenances  and  seeks  to  be  restrained  from,  the  morbid  impulse,  or  to 
subvert  the  morbid  feeling. 

Momentary  impulses  and  suggestions  of  a  morbid  kind*  obtrude   themselves  upon 

*  The  great  Mare  relates  of  himself  how  he  withdrew  from  a  bridge  he  was  about  to 
cross,  lest  he  should  yield  to  the  impulse  which  came  upon  him  to  precipitate  himself  into 
the  Seine.  How  many  persons  have  confessed  to  feeling  a  disposition  to  precipitate 
themselves  into  the  water  when  looking  over  a  steep  precipice,  or  the  sides  or  steiui  of  a 
steamer. 


IDIOCY — DEMENTIA — FOLIE   RAISONNANTE.  II5 

many  healthy  minds,  like  the  vague  feelings  of  unreasonable  unrest  and  depression  which 
obtrude  unbidden  into  the  neural  chambers  of  the  cerebral  cortex. 

Facts  like  these,  and  a  hundred  others  needless  to  enumerate,  show  the  capability  of 
the  mental  faculties  to  become  partially  involved  in  aberrant  action  without  notable  de- 
rangement of  the  reason. 

Men  are  not  considered  insane  because  they  do  not  act  wisely  ;  why  should  it  be  in- 
sisted upon  that  the  intellect  should  show  disorder  before  insanity  is  recognized  in  those 
whose  impulsions  are  undoubtedly  of  morbid  source,  and  why  should  the  intellectual  im- 
plication, when  it  is  found,  though  it  be  no  greater  than  that  of  some  men  moved  by 
passion,  be  insisted  upon  as  the  essential  feature  of  the  disease  ? 

How,  then,  can  we  doubt  the  possibility  of  forms  of  emotional  and  impulsive  insanity, 
in  which  the  moral  faculties  are  so  involved  by  disease  as  to  cause  the  individual  to  appear 
depraved?  The  converse,  too,  is  true.  There  may  be  moral  exaltation  from  disease  as 
well  as  from  intellectual  conviction,  even  from  sexual  excitation  (excessive  or  suppressed 
gratification)  religious  exaltation  may  result,  as  Dr.  Workman  and  others  have  shown, 
and  that,  too,  without  ecstatic  visions  or  special  delusions.  Dr.  Benjamin  Rush*  noted 
long  ago  that  a  morbid  state  of  the  sexual  appetite  "  becomes  a  disease  both  of  the  body 
and  mind."  This  pioneer  in  American  psychiatry  and  close  observer  of  the  insane, 
readily  discerned  that  the  will  might  be  deranged  even  "  in  many  instances  of  persons 
of  sound  understandings  and  some  of  uncommon  talents,  the  will  becoming  the  involun- 
tary vehicle  of  vicious  actions  through  the  instrumentality  of  the  passions,"-}-  under  which 
head  he  included  what  he  termed  the  lying  disease,  which  "  differs  from  exculpative, 
fraudulent  and  malicious  lying,  in  being  influenced  by  none  of  tlie  motives  of  any  of 
them."  "  Persons  thus  diseased,"  he  says,  "  cannot  speak  the  truth  upon  any  subject,  nor 
tell  the  same  story  twice  in  the  same  way,  nor  describe  anything  as  it  has  appeared  to 
other  people.  Their  falsehoods  are  seldom  calculated  to  injure  anybody  but  themselves, 
being,  for  the  most  part,  of  a  hyperbolical  or  boasting  nature. "J  He  inferred  it  to  be 
"a  corporeal  disease,"  from  its  sometimes  appearing  in  mad  people,  who  are  remarkable 
for  veracity  in  healthy  states  of  their  minds,  several  instances  of  which  he  saw  in  the 
Pennsylvania  Hospital.  He  recognized  certain  stages  of  intemperance  as  a  disease  of  the 
■will,  and  was  the  first  to  propose  a  hospital  for  inebriates,  or  "  sober  house,"  as  he  termed 
it,  comparing  the  weakened  will  of  a  drunkard  to  a  paralyzed  limb.  Rush  also  believed 
in  a  derangement  of  the  principle  of  faith,  or  the  believing  faculty,  caused  by  disease, 
also  in  derangement  of  memory,  under  which  head  he  includes  some  instances  of  aphasia, 
without  the  accompaniment  of  intellectual  aberration.  He  was  an  unequivocal  believer 
in  derangement  of  the  moral  faculty,  conscience,  and  the  "  sense  of  Deity,"  and  notes 
especially  the  case  of  a  boy  of  thirteen  years,  in  Bethlehem  Hospital,  described  by  Has- 
1am,  "  who  was  perfectly  sensible  of  his  depravity,  and  often  asked  why  God  had  not 
made  him  like  other  men."  In  the  course  of  his  life.  Dr.  Rush  was  consulted  in  many 
of  "  those  cases  of  total  perversion  of  the  moral  faculties."  "  Oife  of  them  was  addicted 
to  every  kind  of  mischief.  Her  wickedness  had  no  intervals  while  awake,  except  when 
she  was  kept  busy  in  some  study  or  difficult  employment." 

This  great  observer  concluded  that  in  these  cases  "  there  is  probably  an  original  de- 
fective organization  in  those  parts  of  the  body  which  are  occupied  by  the  moral  faculties 
of  the  mind,"g  though  he  could  not  determine  where  to  draw  the  line  which  divides  free 
agency  from  necessity,  and  vice  from  disease.     He  discourses  further  as  follows : 

"  In  whatever  manner  this  question  may  be  settled,  it  will  readily  be  admitted  that 

*  New  Obs.  and  Enquiries,  1812,  p.  347.  |  Op.  cit.,  p.  264. 

X  Op.  cit.,  p.  265.  g  Op.  cit.,  p.  360. 


Il6  PSYCHOLOGICAL    MEDICINE. 

such  persons  are,  in  a  pre-eminent  degree,  objects  of  compassion,  and  that  it  is  the  busi- 
ness of  medicine  to  aid  both  religion  and  law  in  preventing  and  curing  their  moral  alien- 
ation of  mind."* 

Thus  did  one  of  the  fathers  of  American  medicine  contribute  in  the  beginning  of  the 
present  century  to  the  overthrow  of  that  opprobrious  doctrine  of  diabolical  possession, 
or  moral  depravity,  which  has  led  many  a  hapless  lunatic  to  the  stake  or  the  gallows,  and 
to  give  us  in  its  stead  the  conception  of  moral  mania,  a  form  of  insanity  just  as  real  as 
the  demonomania  which  overtook  unfortunate  old  women  past  the  menstrual  climacteric 
m  Cotton  Mather's  day,  and  resulted  in  their  being  drowned  for  witchcraft,  and  which, 
notwithstanding  the  reality  of  disease  for  its  cause,  finds  even  now  in  some  quarters 
neither  commiseration  nor  extenuation,  being  regarded  as  the  manifestation  of  a  wicked 
and  devilish  spirit,  entitling  its  possessor  to  the  punishment  of  the  gallows  or  the  peni- 
tentiary, rather  than  the  restraint  and  treatment  of  the  asylum  for  the  insane.  The  ex- 
istence of  the  knowledge  of  right  and  wrong  with  the  judge,  the  absence  of  appreciable 
intellectual  disorder  with  the  physician,  are  regarded  as  incompatible  with  their  ideal 
conception,  not  of  what  insanity  is,  but  of  what  it  to  them  ought  to  be,  and  the  penalty 
for  this  theoretical  misconception  of  the  real  nature  of  mind  is  visited  on  the  unfortunate 
victim  of  disease,  whose  bad  luck  it  is  to  be  afflicted  in  a  manner  theoretically  proscribed. 
Theoretical  views  and  metaphysical  conceptions  of  mind  have  too  long  stood  in  the  way 
of  true  progress  in  psychological  knowledge.  To  this  has  been  due  the  fact  that  physi- 
cal disease,  as  the  basis  of  all  forms  of  mania,  now  a  generally  accepted  truth,  was  so 
long  controverted.  To  this  stumbling-block  are  we  indebted  for  the  inhuman  treatment 
the  insane  received  in  the  time  of  Galen,  and  up  to  that  comparatively  recent  period  when 
Pinel  immortalized  himself  and  lifted  humanity  to  a  higher  pedestal  by  striking  the 
shackles  from  the  madmen  in  the  dungeons  of  Bicetre. 

There  is  a  somatic  as  well  as  a  psychic  element  in  mind  as  we  are  permitted  to  see  it, 
to  be  taken  account  of  in  all  study  of  psychical  display,  whether  in  health  or  disease, 
though  what  mind  is  we  do  not  know,  and  perhaps  we  may  never  completely  compre- 
hend, save  in  its  manifestations.  All  that  we  can  see  of  mind  is  displayed  in  the  opera- 
tions of  the  intellect,  the  emotions,  feelings,  and  the  v.ill.  There  is  a  time  in  life  when 
we  see  but  little  of  the  former,  and  a  time  when  we  see  more  of  it  than  of  the  two  latter 
attributes  of  the  accompaniments  of  mind.  The  emotions  and  the  will  are  part  of  the 
mind,  as  it  manifests  itself  to  us;  and  whatever  may  be  our  preconception  of  the  impos- 
sibility of  their  being  separated,  if  we  see  them  practically  severed  by  disease,  it  is  only 
just  to  acknowledge  the  fact. 

To  assert  that  the  doctrine  of  moral  insanity  is  a  dangerous  one,  from  which  society 
may  suffer,  as  Mayo  and  his  followers  have  done,  is  to  render  science  subservient  to  social 
polity,  illogical,  cowardly,  and,  of  course,  unscientific,  whereas  social  polity  should  be 
ever  subservient  to  scientific  truth,  whatever  that  may  be  revealed  to  be.  Let  us,  always 
speak  according  to  our  convictions.  If  we  trim  and  prune  truth  so  that  we  may  adopt 
it  to  social  expediency,  we  become  false  lights;  we  degrade  science,  the  sceptre  of  influ- 
ence falls  from  us,  and  judicial  wrongs,  even  murder  perpetrated  by  strong-handed  Law 
upon  the  weak  and  miserable,  will  continue  to  be  committed  in  our  name,  and  be  the 
lasting  monument  of  our  disgraceful  surrender  of  truth. 

There  is  moral  perversion  and  degeneration  resulting  from  disease,  with  but  little,  if 
any,  appreciable  intellectual  lesion,  less  intellectual  lesion  oftentimes  than  we  find  in 
those  whose  lives  have  been  given  up  to  vice,  through  self-will,  or  parental  coercion,  or 
evil  communication.     Then  let  us,  when  occasion  demands,  tell  the  courts  so,  and  not 

*  Op.  cit.,  p.  300. 


IDIOCY — DEMENTIA — FOLIE    RAISONNANTE.  11/ 

say  we  cannot  conceive  it  possible  for  moral  derangement  to  exist  without  concomitant 
intellectual  aberration,  while  observable  facts  confute  such  theories,  and  let  us  turn  our 
attention  to  searching  out,  for  the  aid  of  jurists,  instead  of  ignoring  the  line  of  demarca- 
tion between  responsible  and  irresponsible  vice  ;  the  characteristics  of  disease  on  the  one 
hand,  and  on  the  other,  voluntary  moral  depravity  coupled  with  a  body  sound  and  a 
mind  free  to  choose. 

Moral  insanity  constitutes  an  observed  and  observable  fact  of  psychology;  let  us  not 
seek  to  theorize  it  out  of  existence. 

The  metaphysical  conception  of  mind,  the  abstraction  made  into  an  entity,  as  Maudsley 
justly  observes,  "has  overridden  discerning  observation"  in  some  quarters,  and  eminent 
and  observing  men  have  thus  suffered  their  judgments  to  become  biased  by  the  idea  that 
the  faculties  of  the  mind  cannot  act  separately ;  that  to  derange  one  must  necessarily  and 
appreciably  disorder  others. 

On  this  reasoning,  many  eminent  men  believe  the  existence  of  moral  insanity  impossi- 
ble, while  others,  among  them  the  lamented  Ray,  not  so  biased,  following  in  the  footsteps 
of  Prichard,  who  first  promulgated  the  doctrine,  see  no  more  difficulty  in  recognizing 
insanity  of  the  moral  feelings,  and  of  other  impulses,  propensities  and  passions,  without 
necessary  involvement  of  the  higher  faculties  of  reasoning  in  appreciable  disorder,  than 
the  great  Pinel  did  long  before  them  in  discerning  what,  up  to  his  time,  was  regarded  as 
equally  inexplicable,  namely,  mania  without  the  delirium  of  madness. 

Dr.  Mayo,*  who  made  the  first  and  strongest  assault  on  the  doctrine  of  Prichard,  has 
unwittingly  admitted,  as  indeed  all  close  observers  of  insanity  know,  "  that  the  earliest 
indications  of  approaching  insanity  are  moral,"  and  he  makes  the  further  fatal  admission, 
"  that  at  every  period  of  the  actual  presence  "  of  insanity  "  the  powers  of  self-control  are 
interfered  with,  the  affections  suppressed  or  altered,  the  passions  excited  or  perverted." 

All  practical  observers  concede  a  frequent  gradual  change  of  feeling  and  conduct  in 
prodromal  insanity  preceding  the  culmination  of  intellectual  aberration,  and  some  who 
deny  the  possibility  of  moral  insanity  make  a  classification  of  moral  imbecility,  conces- 
sions which  logically  debar  all  opposition  to  moral  insanity. 

Whatever  the  stage  at  which  we  view  mental  disease,  whether  initial  or  terminal,  in- 
sanity exists,  as  much  so,  as  fever  at  any  stage  of  typhoid  or  typhus  is  fever.  If  a  change 
of  moral  conduct  have  disease  for  its  cause,  it  is  as  much  entitled  to  be  called  insanity  as 
the  morbid  aversions,  antipathies,  fears,  or  acts,  not  brought  about  by  delusion,  are  to  be 
classed  among  the  recognized  evidences  of  mental  derangement. 

Blandford's  searching  analysis  of  Prichard's  cases,  while  it  divests  many  of  them  of 
the  vestments  of  uncomplicated  moral  insanity,  leaves  a  number  that  cannot  be  elsewhere 
placed,  "  good  examples  of  what  may  be  called  moral  insanity,  if  the  term  is  to  be  used 
at  all,"  as  Blandford  himself  confesses,  one  of  which  he  concedes  deserves  to  be  called 
morally  insane. j 

Those  who  engage  in  the  study  of  morbid  mental  phenomena  with  the  preconception 
that  the  intellect  must  be  always  synchronously  deranged  in  all  morbid  mental  expression, 
must  consistently  regard  every  act  or  feeling  of  the  insane  person  "  as  plainly  the  out- 
come of  some  idea  present  for  the  moment,  but  present,  possibly,  but  for  the  moment, 
and  then  so  obliterated  that  the  individual  has  lost  all  trace  of  it,"J  in  certain  morbid 
impulsions  or  feelings.  Those  who  think  "  the  intellectual  and  emotional  functions  of  the 
mind  cannot  be  divorced,  that  the  ideational  portion  of  the  mind  is  so  intimately  joined 

*  Elements  of  the  Pathology  of  the  Human  Mind,  Medical  Testimony  and  Evidence 
in  Cases  of  Lunacy.     By  Thomas  Mayo,  M.D.,  F.R.S.,  London,  p.  64. 

f  Cases  4  and  5,  p.  317.     Insanity  and  its  Treatment,  1871.  %  Ibid.,  p.  319. 


Il8  PSYCHOLOGICAL    MEDICLXE. 

in  operation  to  the  emotional — the  stored  ideas  of  the  brain  are  so  influenced  by  the 
feelings  of  the  moment,  whether  these  arise  from  within  or  without — that  the  two  must 
be  sound  or  unsound  together,"  will  be  reluctant  to  concede  the  demonstrable  fact  that 
the  aftective  life  may  be  greatly  changed  by  disease,  while  the  intellectual  processes  re- 
main intact,  so  far  as  may  be  discernible  by  any  known  methods  of  testing  the  integrity 
of  the  reasoning  powers ;  slow  to  recognize  those  cases  in  which  the  will  and  not  the 
reason  is  weakened  and  perverted.  Yet  the  morbid  impulsions  arising  in  neuropathic 
organisms,  often  reasoned  against  and  sometimes  resisted,  but  finally  surrendered  to,  stand 
out  m  practical  refutation  of  the  impossible  conception  of  the  invariable  unity  of  mind 
disturbed  by  disease. 

The  dipsomaniacs,  the  kleptomaniacs,  and  sometimes  even  pyromaniacs,  yielding  to  im- 
pulses against  their  reason,  are  examples  no  less  destructive  to  this  hypothesis  than  the 
auto-amnestic  acts  and  impulses  of  hypnotism,  somnambulism,  and  certain  epileptoid 
states.  To  gauge  insanity  by  the  integrity  or  non-integrity  of  the  reasoning  processes 
alone  would  make  the  automatism  of  certain  manifestations  of  alcoholism,  epilepsia  and 
mesmerism  normal  mental  states.  The  reasoning  faculties  in  moral  insanity  often  appear 
to  act  as  correctly  as  in  the  most  perfect  cerebral  automatism.  If  there  is  lesion  short  of 
intellectual  disease  and  beyond  that  of  pure  derangement  of  the  moral  faculties,  and  there 
usually  is  in  this  as  there  is  in  all  insanity,  a  degree  of  auto-amnesia  by  which  the  affected 
individual  does  not  discern  the  change  that  has  taken  place  in  himself,  it  is  simply  an 
impaired  or  lost  appreciation  of  the  transformation  in  his  character,  which  has  been 
brought  about  bj^  disease,  but  many  sane  persons  also  fail  to  discern  their  descent  into 
vicious  ways.  However,  if  this  degree  of  involvement  of  the  comparing  faculties  be 
deemed  sufficient  to  ally  it  to  insanity  in  general  (and  it  does  on  the  basis  of  a  part  of 
Conolly's  definition),  and  thus  to  rescue  a  real  mental  disease  from  the  theoretical  assaults 
made  upon  it,  we  cheerfully  concede  it,  for  it  is  a  fact  that  the  morally  insane,  like  most 
other  insane  persons,  usually  do  not  see  themselves  as  others  see  them.  But  there  are 
cases  where  the  search  must  be  exceedingly  close  to  reveal  any  greater  lesion. 

Normal  mind  is  the  sum  of  the  aggregate  display  of  the  cerebro-psychic  functioiis  con- 
stituting the  natural  "  ego,"  abnormal  mind  consists  of  such  disorder  of  one  or  more  of 
the  cerebro-psychic  functions  as  causes  so  marked  a  change  in  the  psychical  characteris- 
tics of  the  individual,  whether  principally  involving  the  emotions,  the  reasoning  powers, 
or  the  will,  as  to  make  an  inconsistency  and  inharmony  in  the  person's  character  explica- 
ble only  by  disease. 

Moral  insanity  is  as  clearly  comprehended  in  this  definition  as  other  forms  of  mental 
derangement,  and  as  much  entitled  to  be  recognized  as  a  distinctive  appellation  and  form 
of  disease  as  the  many  other  mental  affections  that  are  named  on  account  of  their  promi- 
nent symptomatic  feature  or  features. 

Not  to  recognize  it  in  the  present  state  of  cerebro-mental  pathology  would  in  certain 
instances  prove  disastrous  to  the  rights  of  the  insane  before  the  courts,  and  to  their  wel- 
fare elsewhere. 


MENTAL   RESPONSIBILITY,    ETC.,    IN    CRIMINAL    CASES.  I  I9 


CHAPTER  VIII. 

MENTAL  RESPONSIBILITY  AND  THE  DIAGNOSIS  OF  INSANITY  IN  CRIMINAL 

CASES. 

At  the  present  day  medico-legal  cases  are  becoming  very  frequent 
in  which  it  is  necessary  to  ascertain  as  to  the  insanity  of  a  person 
accused  of  a  criminal  act  in  its  relation  to  his  civil  capacity  and 
responsibility  for  criminal  actions,  and  also  as  to  feigned  or  concealed 
insanity.  It  becomes,  therefore,  a  very  interesting  question  what 
test  of  insanity  the  law  should  recognize  as  a  valid  defence  in  crimi- 
nal cases.  This  question — although  one  which  it  seems  difficult  to 
settle  satisfactorily,  and  which  judges,  lawyers,  and  medical  experts 
are  constantly  disputing  about — assumes,  every  day,  greater  interest 
and  wider  significance  owing  to  the  increase  of  insanity  in  our  coun- 
try disproportionate  to  the  increase  of  population  which  has  taken 
place  during  the  past  twenty  years,  and  which  will  continue  to  take 
place.  Without  inserting  dry  statistics,  it  is  sufficient  to  say  that  a 
comparison  of  the  increase  of  population  from  1850  to  1870  with  the 
increase  of  the  number  of  the  insane  during  the  same  period  reveals 
an  increase  of  insanity  over  that  of  population  of  about  twelve  per 
cent. 

The  increase  of  insanity  among  our  own  population  is  due  largely 
to  a  change  from  a  vigorous,  well-balanced  organization  to  an  undue 
predominance  of  the  nervous  temperament  which  is  gradually  taking 
place  in  successive  generations.  The  educational'  pressure  on  the 
young  to  the  neglect  of  physical  exercise,  the  increasing  artificial  and 
unnatural  habits  of  living,  the  great  excitement  and  competition  in 
business,  are  all  tending  to  induce  and  multiply  nervous  diseases, 
many  of  which  must  terminate  in  insanity.  These  causes  and  the 
evils  resulting  from  them  are  propagated  by  the  laws  of  inheritance 
in  an  aggravated  and  intensified  form.  Insanity  is  also  appearing 
gradually  at  an  earlier  age  than  formerly. 

This  is  due  largely  to  the  great  mental  activity  and  strain  upon 
the  nervous  system  that  appertain  to  the  present  age  and  state  of 
civilization,  and  which  tend  to  a  rapid  decay  of  the  nervous  system. 
With  many  persons  it  is  but  a  step  from  extreme  nervous  suscepti- 
bility to  downright  hysteria,  and  from  that  to  overt  insanity.  The 
question  of  mental  responsibility  in  its  relation  to  criminal  cases  is 


I20  PSYCHOLOGICAL    MEDICINE. 

one  of  great  interest,  and  presents  a  wide  field  for  study  and  investi- 
gation. The  facts  of  criminal  psychology  have  led  the  writer  to 
regard  the  impulse  of  criminal  natures  in  the  light  of  natural  laws, 
and  there  is,  beyond  all  doubt,  an  anthropological  change  which  lies 
at  the  foundation  of  criminal  propensities.*  There  is  a  deficient  cere- 
bral organization  which  lies  at  the  foundation  of  these  criminal  na- 
tures, which  occasions  the  disposition  to  an  abnormal  moral  consti- 
tution. The  dislike  of  work  and  the  love  of  enjoyment  are  impulses 
which,  when  combined,  lead  especially  to  crime,  when  that  ethic  con- 
stitution or  development  is  wanting  which  is  necessary  to  the  foun- 
dation of  a  powerful  feeling  of  what  is  right.  A  further  fundamental 
element,  which  stands  in  psycho-physical  contrast  to  dislike  of  work, 
is  an  excessive  physical  consciousness  of  strength,  which  leads  to 
arrogance  and  thereby  to  the  pleasure  of  misusing  strength  against 
the  weak.  This  impulse  leads  to  the  love  of  bullying,  cruelty,  and 
murder,  if  the  higher  intellect  is  absent  which  should  turn  the  feeling 
of  strength  in  a  right  direction,  and  there  is  also  absent  a  complete 
ethical  consciousness  which  should  prevent  misuse  of  power.  This 
ethical  weakness  may  be  congenital,  as  has  been  remarked,  or  it  may 
arise  from  deficient  education. 

In  the  domain  of  vices  we  meet  with  a  peculiar  condition  of  the 
central  nervous  system,  which  results  in  a  temporary  criminal  im- 
pulse returning  with  a  certain  regularity.  Such  criminals  are  tem- 
porarily seized  with  the  deepest  remorse  and  are  fortified  with  the 
best  resolutions.  They  behave  for  a  time  in  the  most  exemplary 
manner,  until  they  relapse  again,  which  relapse  is  unanimously 
attributed  by  them  to  an  irresistible  impulse.  This  state  of  moral 
epilepsy  is  of  great  significance  in  the  psychology  of  crime,  as  a  physi- 
ologist is  led  to  institute  a  comparison  between  such  cases  and  sev- 
eral states  of  disease  in  which  a  peculiar  type  is  observable,  consisting 
in  the  fact  that  attacks  of  illness  of  more  or  less  duration  alternate 
with  more  or  less  long  and,  generally,  for  a  time,  preponderant, 
healthy  intermissions.  In  a  broad  sense,  one  may  designate  all  these 
pathological  states  as  epileptiform,  hence  the  term  "  moral  epilepsy," 
which  has  been  adopted  above.  Leaving  this  interesting  question  of 
the  psychology  of  crime,  we  would  ask  if  the  true  basis  for  jurists  to 
proceed  upon  is  not  the  protection  of  the  existence  of  normal  persons 
against  the  ethically  degenerate  ?     And  the  necessary  degree  of  this 

*  Benedikt  has  shown  this  conclusively,  and  the  reader  is  referred  to  the  last  chapter 
of  this  work  for  the  full  consideration  of  this  most  interesting  question. 


MENTAL    RESPONSIBILITY,    ETC.,    IN    CRIMINAL   CASES.  121 

protection  is,  most  certainly,  an  essential  measure  for  the  severity  of 
the  punishment.  The  first  trial  of  note  where  there  was  the  question 
of  insanity  advanced  was  in  1723,  when  the  trial  of  Arnold  for  shoot- 
ing at  Lord  Onslow  occurred.  Although  it  was  shown  that  Arnold 
had  been  of  weak  understanding  from  his  birth  and  that  he  was 
doubtless  insane,  the  jury  brought  in  a  verdict  of  guilty,  and  Arnold 
would  have  been  executed  had  it  not  been  for  the  intercession  of 
Lord  Onslow. 

The  language  of  the  charge  to  the  jury  in  this  case  was  in  con- 
formity to  the  rule  laid  down  by  Lord  Hale,  that  partial  insanity  does 
not  excuse  a  person  from  the  consequence  of  his  act,  and  that  a  total 
deprivation  of  reason  can  furnish  such  an  excuse.  In  the  year  1800 
the  celebrated  trial  of  Hatfield  for  shooting  at  the  King,  in  Drury 
Lane  theatre,  excited  much  interest.  Although  it  was  proved  that  in 
1793  Hatfield,  who  was  a  dragoon,  had  received  a  number  of  severe 
wounds  which  had  caused  partial  insanity,  so  that  he  was  dismissed 
from  the  service,  and  since  that  time  he  had  had  periodic  attacks  of 
insanity,  and  had  been  confined  as  a  lunatic,  the  prosecuting  attorney 
laid  down  the  established  rule  that  a  total  absence  of  memory  and 
understanding  could  alone  shield  the  prisoner  from  punishment,  and 
appealed  to  the  jury  for  a  conviction  on  that  ground.  It  was  only 
through  the  brilliancy  of  the  advocate  (afterward  Lord  Erskine)  that 
the  prisoner  was  acquitted.  This  trial  had  a  good  effect  upon  the 
judiciary,  as  in  the  year  18 12,  in  the  trial  of  Bellingham  for  the  mur- 
der of  Spencer  Percival,  Lord  Mansfield  laid  down  the  law  that  the 
capability  of  distinguishing  between  right  and  wrong  was  the  test  for 
determining  the  prisoner's  responsibility,  thus  discarding  the  old 
theory  of  an  entire  absence  of  all  mental  power  and  substituting  this 
in  its  place.  Afterward  the  theory  of  a  general  knowledge  between 
right  and  wrong  was  modified,  and  the  element  introduced  that  the 
prisoner  must  know  the  difference  between  right  and  wrong  at  the 
time  of  and  with  regard  to  the  particular  act  for  which  he  is  on  trial 
in  order  to  render  him  responsible,  and  this  test  has  been  preserved 
to  the  present  time.  In  the  early  history  of  our  own  country  the 
same  barbarism  in  the  treatment  of  the  insane  prevailed  which 
darkens  the  pages  of  English  history.  In  Governor  Winthrop's 
History  of  New  England  the  case  of  Dorothy  Dalbye  is  mentioned. 
She  was  executed  for  killing  her  child.  She  was,  beyond  all  doubt, 
an  insane  woman,  but  this  fact  was  not  recognized  by  Governor  Win- 
throp,  who  says  of  her ;  "  She  was  so  possessed  with  Satan  that  he 


122  PSYCHOLOGICAL    MEDICINE. 

persuaded  her  by  his  delusions,  which  she  hstened  to  as  revelations 
from  God,  to  break  the  neck  of  her  own  child,  that  she  might  free  it 
from  future  misery^"  Such  was  the  ignorance  and  prejudice  of  the 
early  history  of  our  country''. 

We  are  at  the  present  day  very  far  from  a  correct  understanding 
of  the  workings  of  the  insane  mind,  for  in  the  recent  trial  of  Scan- 
nail,  the  law  was  laid  down  as  enunciated  by  the  Court  of  Appeals  in 
1865,  in  the  case  of  Willis  v.  The  People,  which  held  that  a  person  was 
not  insane  who  knew  right  from  wrong,  and  that  the  act  he  was  com- 
mitting was  a  violation  and  wrong  in  itself  This  theory  of  right 
and  wrong  is  utterly  inadequate  to  meet  a  large  class  of  cases. 
There  are  certain  cases  familiar  to  all  specialists  in  insanity,  which 
suffer  from  impulsive  insanity  with  a  homicidal  or  suicidal  mono- 
mania. These  patients,  without  appreciable  disorder  of  the  intellect, 
are  impelled  by  a  terrible  vis  a  tergo,  a  morbid,  uncontrollable  im- 
pulse to  desperate  acts  of  suicide  or  homicide.  These  patients  are 
often  fully  aware  of  their  morbid  state,  appreciate  perfectly  the  nature 
of  the  act  toward  which  they  are  impelled,  and  feel  deeply  the  horror 
of  their  situation,  and  yet  if  not  prevented  by  restraint  will  inevita- 
bly commit  acts  of  suicide  or  homicide. 

A  very  remarkable  case  was  under  the  care  of  the  writer,  of  a  man 
who  would  at  stated  times  acknowledge  that  he  felt  an  irresistible 
impulse  to  kill  some  one,  and  would  voluntarily  enter  an  asylum  and 
remain  there  until  this  morbid  impulse  had  passed  away,  which  was 
generally  a  period  of  one  or  two  months.  He  has  often  told  the 
writer  that  his  life  was  made  miserable  by  the  idea  that  at  some  time 
this  overwhelming  impulse  would  come  upon  him  so  suddenly  that 
he  should  commit  some  desperate  homicidal  act,  but  is  not  pre- 
pared to  voluntarily  incarcerate  himself  in  an  asylum  for  life,  as  his 
lucid  intervals  sometimes  lasted  for  months  at  a  time.  The  law,  as 
laid  down  at  present,  would  not  decide  this  man  to  be  insane,  as  he 
fully  appreciates  the  difference  between  right  and  wrong,  and  the 
nature  and  consequences  of  any  homicidal  act  that  he  may  in  the 
future  commit.  Such  cases,  which  are  not  at  all  uncommon,  serve  to 
show  what  fearful  injustice  may  be  done  under  the  name  of  justice, 
when  the  conclusion  is  based  upon  a  metaphysical  test  which  is 
proved  by  medical  observation  to  be  false  in  its  application  to  the 
unsound  mind.  There  is  still  another  form  of  insanity  denominated 
"  moral  insanit}'-,"  in  which  the  intellectual  faculties  are  intact,  no  de- 
lusions or  hallucinations  existing,  but  where  the  normal  sense  seems 


MENTAL   RESPONSIBILITY,    ETC.,    IN    CRIMINAL   CASES.  1 23 

utterly  obliterated.  Such  persons  have  no  true  moral  feeling.  This 
is  disorder  of  the  mind  produced  by  disease  of  the  brain,  and  it  is 
an  unquestionable  form  of  insanity,  as  it  often  precedes  other  forms 
of  insanity,  in  which  intellectual  derangement  is  well  marked,  as 
acute  mania  or  general  paralysis.  In  some  of  these  cases  there  is  a 
modified  responsibility,  the  degree  of  such  responsibility  being  de- 
termined by  the  particular  circumstances  of  each  individual  case. 
One  difficult  but  important  question  to  be  solved,  is  the  civil  and 
criminal  responsibility  of  women  who  plead  insanity  before  courts  of 
justice,  and  who  are  often  afflicted  with  kleptomania,  pyromania,  or 
who  are  infanticides,  as  a  result  of  sexual  trouble  and  disease  of  the 
pelvic  organs.  Such  women  under  all  reasonable  conditions  are  en- 
titled to  the  benefit  of  the  doubt,  because  of  their  defective  mental 
integrity,  caused  perhaps  by  pregnancy  or  by  the  subsequent  emo- 
tional excitement  attending  parturition,  which  intensifies  the  cerebral 
disorder  in  a  brain  already  morbidly  active. 

With  women,  extreme  nervous  susceptibility  readily  lapses  into 
insanity.  "  In  the  sexual  evolution,  in  the  parturient  period,  in  lac- 
tation, strange  thoughts,  extraordinary  feelings,  unreasonable  appe- 
tites, criminal  and  suicidal  impulses  may  haunt  a  mind  at  other  times 
innocent  and  pure.  It  is  probable  also  that  young  unmarried  women, 
guilty  of  killing  their  own  new-born  offspring,  are  so  distracted  by 
conflicting  feelings,  sharpened  to  morbid  acuteness  by  the  great 
physiological  movement  of  parturition,  as  to  be  hardly  responsible 
for  their  acts."  We  come  now  to  the  question  of  the  diagnosis  of 
insanity. 

In  making  an  examination  of  a  person  accused  of  crime,  and  in 
whom  insanity  is  suspected,  the  person  should  be  visited  by  the 
medical  examiner,  who  should  draw  him  into  a  pleasant  conversa- 
tion, and  inquire  as  to  previous  attacks  of  insanity,  hereditary  his- 
tory, then  into  any  predisposing  causes  of  insanity,  such  as  intem- 
perance, vocation,  habits,  etc.,  which  may  have  operated  in  the 
production  of  insanity.  Also  as  to  injuries  of  the  head  or  spine 
which  may  have  occurred,  sunstroke,  etc.  The  nervous  system 
should  then  be  examined  for  the  existence  of  any  such  diseases  as 
paralysis,  epilepsy,  catalepsy,  or  hysteria.  The  different  senses,  be- 
ginning with  sight,  should  be  examined,  and  in  this  way  it  may  be 
discovered  if  there  are  hallucinations  or  illusions  pertaining  to  any 
of  the  senses.  A  great  many  cases  are  on  the  border  line  which 
separates  sanity  from  insanity,  and  it  often  requires  the  nicest  dis- 


124  PSYCHOLOGICAL    MEDICINE. 

crimination  to  determine  whether  such  a  patient  has  passed  this  bor- 
der Hne.  The  writer  would  suggest  a  series  of  eight  questions,  which, 
if  adopted  by  jurists  in  criminal  cases,  would  prove  a  most  efficient 
and  just  test  as  to  the  existence  of  insanity  in  any  given  case,  viz. : 

1.  Have  the  prisoner's  volitions,  impulses  or  acts  been  determined 
or  influenced  at  all  by  insanity,  and  are  his  mental  functions,  thought, 
feeling  and  action,  so  deranged,  either  together  or  separately,  as  to 
incapacitate  him  for  the  relations  of  life  ? 

2.  Does  the  prisoner  come  of  a  stock  whose  nervous  constitution 
has  been  vitiated  by  some  defect  or  ailment,  calculated  to  impair  its 
efficiency  or  derange  its  operations  ? 

3.  Has  the  prisoner  been  noticed  to  display  mental  infirmities  or 
peculiarities,  which  were  due  either  to  hereditary  transmission  or 
present  mental  derangement  ? 

4.  Has  the  prisoner  the  ability  to  control  mental  action,  or  has  he 
not  sufficient  mental  power  to  control  the  sudden  impulses  of  his  dis- 
ordered mind,  and  does  he  act  under  the  blind  influence  of  evil 
impulses,  which  he  can  neither  regulate  nor  control  ? 

5.  Has  the  act  been  influenced  at  all  by  hereditary  taint  which  has 
become  intensified,  so  that  the  morbid  element  has  become  quick- 
ened into  overpowering  activity,  and  so  that  the  moral  senses  have 
been  overborne  by  the  superior  force  derived  from  disease  ? 

6.  Was  the  act  effected  by  or  the  product  of  insane  delusion  ? 

7.  Was  the  act  performed  without  adequate  incentive  or  motive  ? 

8.  Does  the  prisoner  manifest  excitement  or  depression,  moody, 
difficult  temper,  extraordinary  proneness  to  jealousy  and  suspicion,  a 
habit  of  unseasonably  disregarding  ordinary  ways,  customs  and  ob- 
servances, and  habitual  extravagance  of  thought  and  feeling,  and  in- 
ability to  appreciate  nice  moral  distinctions ;  and,  finally,  does  he 
give  way  to  gusts  of  passion  and  reckless  indulgence  of  appetite  ? 

Some  or  all  of  these  are  found  generally  in  connection  with  trans- 
mitted mental  infirmity.  It  may  be  argued  that  these  mental  defects 
signify  not  mental  unsoundness  but  human  imperfection.  Certainly 
if  we  take  these  manifestations,  any  one  of  them  singly  and  alone, 
we  cannot  claim  such  a  one  as  invariably  an  indication  of  insanity, 
but  on  the  other  hand,  under  certain  circumstances,  each  one  of  them 
may  be  an  unmistakable  sign  of  insanity,  or  rather  of  a  morbid 
cerebral  state  which  may  readily  lapse  into  insanity.  The  disap- 
pointments and  calamities  of  life  obviously  act  with  greater  effect 
upon  an  unstable  mental  organization,  these  causes  of  disturbances 


MENTAL   RESPONSIBILITY,    ETC.,    IN    CRIMINAL   CASES.  12$' 

meeting  with  a  powerful  co-operating  cause  in  the  constitutional 
predisposition.  Sometimes  a  crime  even  when  there  have  been  no 
previous  symptoms  to  indicate  disease,  marks  the  period  when  an 
insane  tendency  has  passed  into  actual  insanity,  when  a  weak  organ 
has  given  way  under  the  strain  put  upon  it.  There  is  a  class  of  per- 
sons with  a  peculiar  nervous  temperament  who  inhabit  the  border- 
land between  crime  and  insanity,  one  portion  of  which  exhibit  some 
insanity,  but  more  of  vice,  and  the  other  portion  of  which  exhibit 
some  vice,  but  a  preponderance  of  insanity ;  and  it  is  very  difficult 
to  form  a  just  estimate  of  the  moral  responsibility  of  such  persons, 
especially  when  we  reflect  upon  the  fact  that  moral  feeling  is  a  func- 
tion of  oganization,  and  is  as  essentially  dependent  upon  the  integrity 
of  that  part  of  the  nervous  system  which  ministers  to  its  manifesta- 
tions, as  is  any  other  display  of  mental  function. 

The  writer  has  met  with  cases  in  which,  as  a  result  of  parental  in- 
sanity, there  has  been  a  seemingly  complete  absence  of  moral  sense 
and  feeling  in  the  offspring,  and  this  has  been  a  true  congenital  dep- 
rivation, or  a  moral  imbecility  so  to  speak;  of  course  such  children 
can  hardly  fail  to  become  criminals.  In  this  connection,  it  is  inter- 
esting to  note  that  moral  degeneracy  often  follows  as  a  sequence 
upon  disease  or  injury  to  the  brain.  A  severe  attack  of  insanity 
sometimes  produces  the  same  effect,  the  intellectual  faculties  remain- 
ing as  acute  as  ever,  while  the  moral  sense  becomes  obliterated. 

When  such  persons  are  acquitted,  on  trial,  of  a  criminal  act  on  the 
ground  of  insanity,  they  should  be  remanded  to  medical  custody,  and 
should  never  be  set  at  liberty  until  the  medical  superintendent  of  the 
asylum  deems  them  fully  recovered;  but  the  commonest  justice 
plainly  indicates  that  such  custodial  restraint  be  of  a  medical  and  not 
of  a  penal  nature.  It  is  a  very  difficult  thing  for  the  laity  to  recog- 
nize how  sane  a  person  may  be  who,  all  the  while,  has  a  greater 
derangement  than  was  ever  suspected  until  something  happens  to 
elicit  the  evidence  of  it,  such  as  an  attack  of  illness  or  severe  mental 
strain,  and  some  unconquerable  impulse  seizes  him,  and  some  homi- 
cidal or  suicidal  act  results,  to  the  great  surprise  of  every  one. 

In  the  same  manner  inebriety  often  appears  in  maturity  as  a  result 
of  ill-health,  mental  shock,  etc.,  and  it  becomes  an  interesting  ques- 
tion as  to  the  degree  of  moral  and  criminal  responsibility  which 
attaches  to  inebriates,  as  inebriety  often  depends  upon  an  abnormal 
organic  development  of  the  nervous  system  that  has  descended  from 
generation  to  generation,  gaining  in  intensity  until  it  manifests  itself 


126  PSYCHOLOGICAL   MEDICINE. 

in  active  inebriety,  and  there  must  certainly  be  a  modified  responsi- 
bility when  homicidal  or  suicidal  acts  are  committed  during  periods 
of  such  abnormal  cerebration.  In  such  cases  a  criminal  act  may  be 
committed  in  consequence  of  cerebro-mental  disease,  without  any  ap- 
parent lesion  of  the  perceptive  and  reasoning  powers.  In  these  cases, 
also,  the  mental  disorder  is  of  a  sudden  and  transitory  character,  not 
preceded  by  any  symptoms  calculated  to  excite  suspicion  of  insanity. 
It  is  a  transitory  mania  or  sudden  paroxysm,  without  antecedent 
manifestation,  the  duration  of  the  morbid  state  being  short  and  the 
cessation  sudden.  In  these  cases  the  criminal  acts  are  generally 
monstrous,  unpremeditated,  motiveless,  and  entirely  out  of  keeping 
with  the  previous  character  and  habit  of  thought  of  the  individual. 
Such  attacks  are  transient  in  proportion  to  their  violence,  and  transi- 
tion occurs  on  the  completion  of  the  act  of  violence.  There  is  an 
instantaneous  abeyance  of  judgment  and  reason,  during  which  period 
the  person  is  actuated  by  mad  and  ungovernable  impulses. 

Closely  allied  to  this  state  of  which  I  have  been  speaking  is  that 
peculiar  psychological  state — the  trance  state — which  also  occurs  in 
inebriety.  There  has  been  very  little  medical  study  of  these  cases, 
although  they  are  of  great  medico-legal  importance.  Crimes  com- 
mitted in  this  state  are  purposeless,  and  there  exists  no  recollection 
of  them  in  the  mind  of  the  sufferer.  By  "  trance  state,"  I  mean  a 
state  where  there  exists  loss  of  memory  and  consciousness  for  a 
time,  varying  from  minutes  to  days,  the  patient  giving  no  evidence 
by  his  acts  of  his  real  condition,  and  very  likely  attending  to  all  of 
the  duties  of  his  business  in  a  quiet,  mechanical  way.  The  mind 
may,  however,  in  this  trance  condition,  act  in  iinacaistomed  lines  of 
thought  and  action,  and,  in  certain  cases,  the  criminal  impulse  may 
dominate  the  mind.  As  a  rule,  in  these  trances,  it  is  probable  that 
the  mind  acts,  as  before,  with  the  same  discretion,  although  the  per- 
son himself  can  give  no  account  of  what  has  happened  during  this 
mental  blank,  during  which  the  mind  acts  automatically.  During 
this  state  a  person  may  get  into  a  dangerous  mental  condition,  in 
which  impulses  of  every  description  may  take  possession  of  and  con- 
trol his  actions.  It  is  a  condition  of  irresponsibility.  In  these  cases 
there  is  generally  a  neurotic  constitution  inherited  from  the  ances- 
tors, and  a  careful  examination,  which  should  never  be  neglected, 
will  generally  reveal  either  intemperance,  insanity,  or  phthisis  in  the 
ancestors.  The  great  diagnostic  point  which  I  would  insist  upon  is 
that  there  is  absolutely  no  recollection  of  what  happens  in  this  trance 


MENTAL    RESPONSIBILITY,    ETC.,    IN    CRIMINAL    CASES.  12/ 

state,  and  this  want  of  memory  cannot  be  successfully  feigned  so  as 
to  deceive  a  careful  expert  in  inebriety  and  insanity.  When  a  per- 
son, either  a  secret  or  an  open  inebriate,  commits  an  unusual  or  crimi- 
nal act  (not  during  intoxication),  and  retains  no  recollection  of  the 
event,  he  should  be  most  carefully  examined  for  the  existence  of  the 
trance  state,  which,  if  it  can  be  proven,  markedly  lessens  the  respon- 
sibility of  his  crime. 

The  impulse  to  crime  in  these  cases  may  develop  in  different  ways. 
There  may  be  suicidal  or  homicidal  impulses,  or  buildings  may  be 
burned,  or  sexual  assaults  may  be  made,  or  be  apparently  very  mali- 
cious. In  all  these  cases  medical  care  is  plainly  indicated.  Persons 
unacquainted  with  this  state  may  reason  that  because  these  crimes 
are  committed  in  a  way  and  manner  perfectly  cool  and  free  from 
excitement,  that  they  are  evidences  of  a  sane  mind,  but  they  are 
greatly  mistaken,  as  it  is  the  rule,  and  not  the  exception,  to  find  these 
deeds  performed  in  a  cool,  quiet  manner,  with  no  excitement.  The 
deeds,  however,  are,  to  the  person  affected,  an  unusual  course  of  action, 
utterly  at  variance  with  the  previous  character  and  habits.  It  is  not 
right  for  inebriates  who  commit  sudden,  purposeless  crimes  to  receive 
the  full  measure  of  punishment  at  the  hands  of  court  or  jury  without 
a  proper  study  of  their  case  by  one  who  has  studied  these  cases  intel- 
ligently. Proper  medical  study  would  enable  courts  and  juries  to 
understand  the  mental  conditions  which  causes  these  motiveless  and 
purposeless  crimes  in  inebriates.  His  act  is  not  a  vice,  and  you  can 
neither  assume  his  perfect  sanity  nor  a  capacity  to  reason  clearly. 
The  person  in  this  trance  state  is  not  cognizant  of  his  acts,  neither,  as 
I  have  said,  does  he  retain  a7iy  recollection  of  them  afterward.  There 
is  absolute  irresponsibility,  and  it  should  be  made  clear  to  both  court 
and  jury.  The  idea  in  these  cases  should  not  be  to  try  to  work  on 
the  sympathies  of  the  jury,  but  to  show  them  the  existence  of  this 
trance  state  and  the  irresponsibility  arising  from  it.  In  these  cases 
we  must  prove  that  inebriety,  as  a  disease,  exists,  and  that  it  has 
affected  intellect,  manner,  temper,  disposition,  habits,  and  character, 
and  then  that  the  trance  state  has  supervened. 

We  will  consider,  finally,  the  medico-legal  importance  of  epilepti- 
form attacks,  which  may  be  partial  in  character,  and  which  may  not 
reach  convulsive  activity  except  so  far  as  the  mind  is  concerned. 
These  attacks  always  display  periodicity,  and  after  the  paroxysm 
there  is  an  intermediate  stage,  during  which,  in  most  cases,  the  per- 
son remains  in  a  confused  state,  perhaps  for  some  hours,  and  is  apt 


128  PSYCHOLOGICAL   MEDICINE. 

subsequently  to  retain  only  a  vague  and  general  notion  of  the  pre- 
ceding events.     Thus  in  a  homicide  by  shooting,  the  murderer  would 
be  likely  to  be  roused  by  the  sound  of  the  pistol-shot  and  to  remem-- 
ber  it,  although  he  would  not  very  likely  remember  the  altercation 
at  all,   or  what  passed  between  himself  and  his  victim.     A  case 
occurred  recently,  of  considerable  interest  from  a  medico-legal  point 
of  view,  in  which  a  murder  was  committed   during  an  epileptiform 
seizure  which  was  the  result  of  a  previous  sunstroke,  the  immediate 
exciting  cause  being  an  attack  of  illness  and  the  taking  of  a  small 
quantity  of  alcoholic  stimulus,  which,  it  is  well  known,  acts  as  a  poi- 
son  upon  persons  who  have  been  sunstruck.     This  state  of  what, 
perhaps,  I  may  not  improperly  call  moral  epilepsy,  in  which  the  man 
was   of  whom  I  shall  presently  speak,  is  a  morbid  affection   of  the 
mind  centres  which  destroys  the  healthy  co-ordination  of  ideas  and 
occasions  a  spasmodic  or  convulsive  mental  action.    The  will  cannot 
always  restrain,  however  much  it  may  strive  to  do  so,  a  morbid  idea 
which  has  reached  a  convulsive  activity,  although  there  may  be  all 
the  while  a  clear  consciousness  of  its  morbid  nature.     The  case  just 
referred  to  had  complained  of  pains  in  the  head  and  sleeplessness, 
which  had  displayed  marked  periodicity  and  which  had  been  accom- 
panied with  great  irritability  of  temper,  excited  by  trifles  and  seem- 
ingly unconnected  with  personal  antipathies.    As  has  been  previously 
stated,  the  person  alluded  to  had  been  suffering  from  quite  a  severe 
illness,  and,  after  taking  a  small  quantity  of  alcoholic  stimulus,  went 
out  to  walk.     He  met  a  friend  with  whom  he  had  been  familiar  for 
years,  and  a  discussion  arose  as  to  the  respective  merits  of  certain 
politicians,  when,  the  discussion  becoming  excited,  the  man  pulled 
out  a  revolver  and  shot  his  friend.     He  then  went,  in  a  confused  and 
dazed  state,  and  sat  for  some  hours  on  a  dock  near  a  river,  and  sub- 
sequently went  home,  and  burst  into  tears,  and  informed  his  wife  of 
the  sad  occurrence,  and  gave  himself  up  at  the  police-station.     There 
was  no  simulation  of  insanity  by  pretending  to  be  incoherent  or  by 
strange  actions,  and  no  attempt,  either  on  the  part  of  himself  or  wife, 
to  pretend  that  the  act  was  an  insane  one.     There  was,  however,  a 
total  blank  in  the  prisoner's  mind  respecting  the  events  preceding 
the   pistol-shot,  which  seemed  to  have  aroused  his  attention  at  the 
time,  and  he  had  no  recollection  of  the  fact  that  he  had  sat  on  the 
dock  for  some  time  afterward,  as  he  was  seen  to  do. 

I  was  consulted  by  Judge ,  who  appeared  for  the  defence,  and, 

upon  ascertaining  the  prisoner's  previous  history,  gave  it  as  my 


MENTAL    RESPONSIBILITY,    ETC.,    IN   CRIMINAL   CASES.  129'' 

Opinion  that  there  had  existed,  for  months  previous  to  the  occurrence, 
a  profound  moral  or  affective  derangement,  which,  from  its  marked 
periodicity,  was  evidently  epileptiform  in  character,  and  that  the  sud- 
den homicidal  outburst  supplied  the  interpretation  of  the  previously 
obscure  attacks  of  recurrent  derangement.  There  had  evidently  been 
induced  by  the  sunstroke  in  this  case  an  epileptiform  neurosis,  which 
had  been  manifesting  itself  for  months,  chiefly  by  irritability,  suspi- 
cion, moroseness,  and  perversion  of  character,  with  periodic  exacer- 
bations of  excitement,  all  foreign  to  the  man  previous  to  the  attack 
of  sunstroke.  It  is  well  known  among  specialists  in  insanity  that 
this  epileptiform  neurosis  often  exists  for  a  long  time  in  an  undevel- 
oped or  masked  form,  and  that  this  neurosis  is,  moreover,  connected 
with  both  homicidal  and  suicidal  mania.  Such  attacks  are  often 
noticed  to  occur  periodically  for  some  time  before  the  access  of  gen- 
uine epilepsy.  I  have  often  witnessed,  in  cases  under  my  care, 
abortive  or  incomplete  epileptiform  attacks,  where  there  were  no  con- 
vulsions and  where  there  was  no  complete  loss  of  consciousness.  I 
have  noticed  in  such  cases,  either  a  momentary  terror,  slight  inco- 
herence, a  gust  of  passion,  or  a  mental  blank,  the  patient  perhaps 
stopping  in  the  middle  of  a  sentence.  The  patient  would  then  be 
himself  again,  quite  unconscious  of  what  had  happened  to  him. 
Accompanying  this  confusion  of  ideas  may  be,  as  I  have  remarked, 
instantaneous  impulses,  either  of  a  suicidal  or  homicidal  nature. 

Owing  to  the  writings  of  Hughlings  Jackson,  Maudsley,  Russell 
Reynolds,  Hammond,  Trousseau,  Falret,  Esquirol  and  others,  epilep- 
tic vertigo  is  a  recognized  disease.  There  is  abundant  testimony  to 
show  that  during  such  seizures  persons  may  perform  actions,  and 
even  speak  and  answer  questions  automatically.  There  are  numer- 
ous examples  in  the  works  of  the  above  authors,  proving  that  in  an 
unconscious  condition  persons  can  progress  from  odd  or  eccentric 
actions  to  deeds  of  violence,  suicide  or  murder — being  unable  to  re- 
member the  circumstances  afterwards  and,  therefore,  irresponsible  for 
their  actions.  This  class  of  patients  I  have  always  found  irritable, 
easily  excited,  very  emotional  without  adequate  external  cause,  easily 
losing  their  train  of  thought,  and  often  unable  to  collect  or  fix  their 
thoughts.  Such  cases  have  told  me  that  they  felt  impelled  to  strange 
and  violent  acts  by  some  power  which  they  could  neither  understand 
nor  resist.  Such  patients  may  entertain  delusions  of  fear  and  per- 
secution, and  commit  criminal  deeds  as  a  result  of  such  delusions. 
When  such  cases,  in  their  terror  or  distress  of  mind,  commit  some 

9 


130  P3VCH0L0GICAL    MEDICINE. 

violent  deed,  they  either  experience  immediate  relief,  as  was  the  case 
with  one  patient  under  my  care,  who  was  only  relieved  by  breaking 
out  a  pane  .of  glass,  when  his  paroxysm  would  subside,  or  they  con- 
tinued in  a  state  of  excitement,  unconscious,  or  very  imperfectly  con- 
scious of  the  gravit}^  of  their  acts.  When  they  become  conscious 
again  their  memory  is  apt  to  be  very  uncertain  as  to  preceding 
events.*  Griesinger  says :  "  Individuals  hitherto  perfectly  sane  and  in 
the  full  possession  of  their  intellects  are  suddenly  and  without  any 
assignable  cause  seized  with  the  most  anxious  and  painful  emotions, 
and  with  a  homicidal  impulse  as  inexplicable  to  themselves  as  to 
others."  ]\Iaudsley  says  :  "  Let  it  be  borne  in  mind  then,  that  there 
are  latent  tendencies  to  insanity  which  may  not  discover  the  least 
overt  evidence  of  their  existence,  except  under  the  strain  of  a  great 

*  The  reader  must  distinguish  between  such  cases  as  the  above  and  cases  of  true  homi- 
cidal mania,  which  latter,  as  Bucknill  and  Tuke  have  shown,  may  be  classified  under  two 
heads  :  i.  Those  cases  in  which  there  is  no  marked  disorder  of  the  intellect,  examples  of 
emotional  insanitj'.  2.  Those  in  which  such  disorder  is  more  or  less  apparent.  The 
former  class  may  be  subdivided  according  as  there  is  or  is  not  evidence  of  premeditation 
and  design.  In  the  latter  class  we  include  cases  marked  by  deficiency  of  intellect,  as 
idiocy,  imbecilit)',  and  a  degree  of  mental  feebleness  not  amounting  to  either  of  these 
states,  while  other  cases  in  the  second  class  are  rather  indicated  by  a  state  of  exaltation, 
shown  by  delusions  or  hallucinations  which  may  constitute  the  motive,  ^^^len  any  per- 
son says  that  they  had  not  the  slightest  motive  for  a  homicidal  act  I  always  stispect  masked 
epilepsy  even  if  there  is  no  proof  of  it,  although  there  is,  of  course,  a  morbid,  overpower- 
ing impulse  to  take  life,  without  intellectual  disorder,  and  with  intact  perception  and 
reasoning  powers.  There  has  been  petit  mal  in  nearly  every  case  of  transitoiy  mania  that 
we  have  knowledge  of.  Griesinger  has  truly  said  that  we  may  have  a  morbid  mental 
state  which  may  present  no  external  manifestation.  Legrand  du  Saulle's  case  of  a  young 
man,  "  Theodore,"  of  twenty-six  years,  who  assassinated  two  men  without  premeditation, 
without  motive,  and  without  apparent  excuse,  was  undoubtedly  a  case  of  epilepsy  com- 
plicated with  transitory  mania.  Castelman,  Devergie,  Calmeil,  Tardieu,  Marce,  have  all 
reported  cases  of  this  nature.  A  young  man  of  education  placed  himself  voluntarily  under 
our  professional  care  acknowledging  impulses  to  commit  homicide,  and  said  that  he  did 
not  like  to  have  razors  or  knives  around  him  for  fear  that  he  should  be  unable  to  resist  these 
impulses.  "  I  never  feel  sure  of  myself,"  he  told  me.  He  evidently  felt  himself  to  be 
irresponsible,  and  expressed  himself  forcibh*  to  me  on  this  point.  I  urged  him  to  volun- 
tarily place  himself  in  a  well-regulated  asylum  for  the  insane,  but  neither  himself  or  his 
family  would  acquiesce  in  this  measure  of  preventive  medicine,  and  he  is  still  at  large. 
He  said  he  had  received  a  blow  on  the  head  and  had  also  suffered  from  heat  prostration 
to  the  extent  of  insensibility,  and  complained  of  cephalalgia.  I  have  had  an  opportu- 
nity of  studying  another  case  of  what  I  think  is  pure  moral  insanity,  where  there  is  an 
utter  moral  insensibility,  and  where  the  whole  channel  of  thought  runs  in  the  direc- 
tion of  how  to  successfully  commit  homicide;  There  are  sexual  perversions  in  this  case. 
There  is  marked  sleeplessness,  but  the  perceptive  and  reasoning  powers  are  veiy  good. 
There  is  premeditation  and  cunning  de:>ign,  and  a  knowledge  of  right  and  wrong.  This 
patient  has  also  suicidal  impulses. 


THE  HISTOLOGY  AND  FUNCTIONS  OF  THE  CEREBRUM.     I3I 

calamity,  or  of  some  bodily  disorder,  and  that  the  outbreak  of  actual 
disease  may  then  be  the  first  positive  symptom  of  unsoundness." 
The  question  as  to  the  degree  of  mental  responsibility  attaching  to 
such  cases  is  one  of  great  interest  to  psychologists  and  also  to  jurists, 
and  one  to  which  it  is  hoped,  in  the  future,  much  more  attention  may 
be  directed  than  has  been  given  to  it  in  the  past. 


CHAPTER  IX. 

THE    HISTOLOGY   AND    FUNCTIONS  OF    THE    CEREBRUM. 

The  study  of  the  histology  and  functions  of  the  cerebrum — not 
alone,  of  the  several  ganglionic  centres,  but  also  of  the  different  layers 
of  the  great  "  hemispherical  ganglia  "  formed  by  the  convolutions  of 
the  cerebrum — has  as  yet  been  little  prosecuted.  It  presents  a  wide 
field  for  investigation,  experimental  inquiry  and  discovery;  and  al- 
ready such  investigators  as  Dr.  Ferrier,  Sir  Charles  Bell,  Dr.  Carpen- 
ter, Dr.  Brown-Sequard,  Charcot,  Pitres,  Maragliano,  and  Tambu- 
rini  have  thrown  great  light  upon  the  localization  of  brain  functions. 

We  may  now  regard  it  as  established  that  the  ascending  parietal 
convolution  of  the  brain  is  connected  in  its  innermost  and  superior 
part  with  the  motility  of  both  the  upper  and  lower  limbs ;  in  its 
middle  part  with  the  motility  of  the  fore-arm  and  head,  and  in  its 
external  or  inferior  part  with  the  facial  muscles.  Also,  that  the  as- 
cending frontal  convolution  in  its  most  external  or  inferior  part, 
where  the  third  frontal  has  its  origin,  is  the  motor  centre  for  the  mus- 
cles of  the  lips  and  the  tongue,  a  function  which  is  also  shared  in  by 
the  foot  of  the  third  frontal  convolution.  In  these  last-named  corti- 
cal centres,  the  transformation  of  ideas  and  verbal  images  into  motor 
impulse  towards  the  muscles  destined  for  the  pronunciation  of  words 
takes  place.  Paralysis,  atrophy,  and  convulsive  movements  will  pre- 
vail in  any  given  case  as  a  rule,  in  the  limb  or  limbs  whose  cortical 
centre  is  most  profoundly  affected  by  destructive  disease,  while  in  epi- 
lepsy, from  the  region  of  the  body  where  the  convulsive  movements 
commence,  which  open  the  epileptic  access,  we  may  with  security 
diagnosticate  the  cortical  centre  primitively  and  principally  affected, 


132  PSYCHOLOGICAL   MEDICINE. 

which  is  that  corresponding  to  the  group  of  muscles  earliest  brought 
into  action. 

The  functions  of  the  cerebellum  are  supposed  to  be  related  to  co- 
ordination, as  in  cerebellar  affections  we  have  a  sort  of  reeling  gait, 
with  severe  vertigo,  and  perhaps  also  severe  and  continuous  vomit- 
ing, while  psychic  disorders  are  lacking,  except  in  general  atrophy  of 
the  cerebellum.  These  symptoms,  however,  cannot  be  considered 
as  pathognomonic  always,  as  they  are  also  present  in  other  central 
nervous  affections. 

Respecting  the  pons  varolii,  we  may  diagnose  with  certainty  recent 
hsemorrhages  into  this  part  where  its  especial  cross  paralysis  is  pres- 
ent, and  we  may  diagnose  the  same,  with  probability,  when  the  apo- 
plectic attack  is  accompanied  with  general  convulsions,  contraction 
of  the  pupils,  and  death  occurs  in  a  few  hours. 

Respecting  the  medulla  oblongata,  it  is  only  with  approximate  cer- 
tainty that  we  can  diagnose  lesions  here.  The  various  cranial  nerves 
are  implicated,  producing  dysarthria,  anarthria,  dysphagia,  aphonia, 
and  disturbances  of  respiration  and  circulation.  We  may  find  either 
hemiplegia  or  paraplegia,  but  very  little  aneesthesia,  as  a  rule. 

In  lesions  of  the  crura  cerebri  we  find  a  paralysis  of  the  motor 
oculi,  generally  affecting  all  its  branches  on  the  same  side  with  the 
lesion  and  opposite  the  contralateral  hemiplegia  of  the  extremities. 
In  these  cases  the  paralysis  both  of  the  extremities  and  of  the  motor 
oculi  is  sudden  and  simultaneous. 

Respecting  the  corpus  striatum  we  know  that  by  far  the  greater 
number  of  cerebral  hsemorrhages  take  place  into  this  ganglionic  cen- 
tre, and  we  accordingly  find  generally  as  the  symptoms  of  lesions 
here  the  typical  hemiplegia. 

We  have,  however,  lesions  affecting  different  localities  of  the  corpus 
striatum  as  laid  down  by  Nothnagel  and  Charcot.  Lesions  affecting 
the  lenticular  nucleus ;  the  caudate  nucleus  ;  the  anterior  portion  of 
the  internal  capsule ;  the  posterior  portion  of  the  internal  capsule ; 
and  finally,  lesions  affecting  only  the  lenticular  nucleus,  or  the  optic 
thalamus,  or  the  adjoining  part  of  the  island  of  Reil.  The  hemiple- 
gia produced  by  haemorrhage  into  the  corpus  striatum  may  gradually 
disappear  if  the  lenticular  or  the  caudate  nucleus  alone  is  involved. 
It  is  permanent  if  the  internal  capsule  is  affected  either  alone  or  with 
the  gray. nuclei.  In  these  lesions  of  the  internal  capsules  with  the 
permanent  paralysis  we  frequently  find  secondary  contractures. 

Respecting  the  cortex  of  the  brain  we  may  say  that  psychic  dis- 


THE  HISTOLOGY  AND  FUNCTIONS  OF  THE  CEREBRUM.     1 33 

orders  in  general  point  to  a  cortical  lesion,  and  dysphagic  and  apha- 
sia phenomena  also  point  in  the  same  direction.  The  third  left 
frontal  convolution  may  be  supposed  to  be  affected  in  simple  ataxic 
aphasia.  The  third  temporal  convolution  may  be  supposed  to  be 
the  seat  of  the  lesion  in  word-deafness.  As  I  have  previously  stated, 
the  motor  disorders  accompanying  cortical  lesions  give  evidence  of 
the  locality  of  the  latter. 

The  forms  of  paralysis  which  we  meet  with  as  a  result  of  cortical 
lesions  are  monoplegias,  partial  hemiplegias,  isolated  paralysis  of  the 
facial  and  hypoglossal  nerves,  of  the  arm,  and  rarely  of  the  leg.  As 
the  result  of  haemorrhage,  softening,  or  the  development  of  a  tumor, 
we  find  certain  forms  of  motor  irritative  phenomena — partial  and 
limited  convulsions.  In  cases  where  the  motor  irritative  phenomena 
take  on  the  character  of  epileptic  attacks,  the  typically  recurring 
spasm  always  begins  in  the  same  group  of  muscles  in  one  extremity 
or  one  half  of  the  face. 

We  know  very  little  positively  of  the  different  operations  of  psy- 
chological and  intellectual  life,  the  phenomena  of  which  have  been 
but  slightly  noticed,  and  are  open  to  discussion.  Mental  diseases 
depend  upon  a  physical  lesion  of  the  central  nervous  system,  and  as 
there  is  a  very  close  relation  existing  between  the  regular  functional 
activity  of  a  normal  brain  and  the  diverse  functional  manifestations 
in  insanity,  the  study  of  the  structure  and  functions  of  the  successive 
ganglia  which  compose  the  brain  is  a  matter  of  deep  interest  as  well 
as  necessity  to  students  of  psychology.  The  white  substance  of  the 
hemispheres  consists  of  medullated  nerve-fibres  of  about  0.0026  to 
0.0067  mm.  in  diameter,  while  at  the  surface  of  the  larger  ganglionic 
masses  and  towards  the  cortex  some  non-medullated  fibres  are  seen. 
The  fibres  of  the  white  matter  are  separated  from  one  another  by 
bands  of  delicate  connective  tissue — fibrillated  sustentacular  matter, 
in  which  are  situated,  at  intervals,  round  or  oval  nuclei,  smooth  in 
contour  and  measuring  0.0093  to  0.0075  ^'^-  These  fibres  of  the 
white  matter  may  be  divided  very  properly  in  two  classes:  i.  Those 
having  a  radiating  and  converging  direction  or  course;  and  2.  Those 
uniting  the  two  halves  of  the  cerebrum  and  forming  the  corpus  cal- 
losum,  which  is  properly  to  be  looked  upon  as  a  physiological  as 
well  as  an  anatomical  commissure,  and  it  is  often  found  to  be  absent 
in  congenital  idiots.  The  cortex  of  the  cerebrum  or  gray  matter  of 
the  convolutions  is  divided  into  several  layers  or  laminse,  the  number 
being  variously  estimated  by  different  observers,  among  whom  are 


134  PSYCHOLOGICAL    MEDICINE. 

Koelliker,  Arndt,  Meynert,  and  Frey.  The  latter  regards  the  cortex 
as  divisible  into  six  laminse.  The  general  plan  of  structure  of  the 
gray  matter  of  the  cerebrum  is,  primarily,  a  wide-meshed  network  of 
medullated  fibres,  in  whose  interstices  ganglion  cells  are  situated. 
We  also  find  that  very  delicate  network  of  fine  fibres  met  with  in  the 
gray  matter  of  the  spinal  cord,  first  discovered  by  Deiters,  which 
consist  of  very  delicate  fibrillae,  springing  from  the  broad  protoplasm 
processes  of  the  ganglion  cell.  These  fibrillae  Deiters  regards  as  a 
system  of  secondary  axis  cylinders  for  the  most  delicate  nerve-fibres. 
Gerlach  first  described  the  network  as  occurring  in  the  cortex  of  the 
cerebrum  as  in  the  spinal  cord.  The  remainder  of  the  gray  matter 
is  made  up  of  the  delicate  sustentacular  substance  before  alluded  to 
as  intervening  between  the  fibres  of  the  white  matter.  In  the  super- 
ficial layers  of  the  convolutions  the  cells  are  small  multipolar  nerve- 
cells,  analogous  to  the  small  cells  in  the  posterior  cornua  of  the  cord, 
while  in  the  deeper  stratum,  or  fourth  layer  of  Frey,  are  found  large 
multipolar  ganglion  cells  0.025  to  0.040  mm.  in  diameter,  presenting 
oval  or  roundish  nuclei.  These  large  cells  correspond  to  the  large 
cells  in  the  anterior  cornua  of  the  spinal  cord,  which,  it  will  be  remem- 
bered, send  out  "  axis  cylinder  processes,"  which  are  prolonged  into 
the  nerve-fibres  of  the  motor  roots.  In  like  manner  we  observe, 
under  the  microscope,  an  "  axis  cylinder  process  "  given  off  from 
these  multipolar  ganglion  cells  of  the  deeper  layers  of  the  convolu- 
tions of  the  cerebrum,  which  process  is  prolonged  into  one  of  the 
nerve-fibres  of  the  corona  radiata.  It  is,  I  think,  demonstrable  that 
there  is  a  lateral  anastomosis  between  the  cells  of  each  layer  or 
lamina,  and  also  anastomoses  between  the  successive  layers  of  the 
convolutions.  Of  course  it  is  impossible  to  limit  exactly  the  special 
attributes  of  any  particular  group  of  cells  in  the  convolutions  of  the 
cerebrum,  yet,  by  comparing  them  with  the  elements  of  the  spinal 
cord,  it  certainly  seems  possible  to  make  certain  legitimate  inductions 
relative  to  their  diverse  activities. 

I  have  just  stated  that  the  large  nerve-cells  of  the  convolutions  cor- 
respond to  the  multipolar  ganglion  cells  of  the  anterior  cornua  of  the 
spinal  cord,  which  cornua  are  connected  with  the  motor  roots  of  the 
spinal  nerves,  while  the  small  and  superficial  cells  of  the  convolutions 
are  analogous  to  the  small  cells  of  the  posterior  cornua  of  the  cord, 
which  are  connected  with  the  sensory  roots  of  the  spinal  nerves. 
We  have  also  seen  that  in  both  the  multipolar  ganglion  cells  of  the 
deeper  layers  of  the  convolutions  of  the  cerebrum  there  exist  pro- 


THE    HISTOLOGY   AND    FUNCTIONS    OF    THE    CEREBRUM.  I  ^5 

cesses  which  become  the  axis  cylinders  of  nerve-fibres.  I  think, 
therefore,  that  we  may  fairly  conclude  that  the  superficial  layers  or 
laminae  of  the  convolutions  of  the  hemispheres  disseminate  the  im- 
pression of  general  sensibility,  and  that  the  deeper  layers,  containing 
the  larger  multipolar  ganglion  cells,  originate  motor  impulses.  It  will 
be  understood  that  in  speaking  of  the  structure  and  functions  of  the 
gray  matter  of  the  hemispherical  convolutions  I  refer  to  the  histo- 
logical elements,  the  functional  activities  of  which  we  are  as  yet  com- 
paratively unacquainted  with. 

The  cerebral  ganglia  whose  structure  and  functions  remain  to  be 
considered  are  the  corpora  quadrigemina,  thalami  optici,  and  corpora 
striata.  The  structure  of  the  corpora  quadrigemina  consists  of  a 
white  layer  overlaid  with  a  zonal  stratum  of  nerve-fibres.  Under- 
neath them  the  crura  cerebelli  and  corpora  quadrigemina  pass  on  to 
reach  the  cerebrum,  and  should  more  properly  be  called,  as  Frey 
remarks,  crura  cerebelli  ad  cerebrum.  Laterally  there  enter  the  cor- 
pora quadrigemina,  from  below,  the  two  lemnisci  arising  from  the 
motor  tract  of  the  medulla  oblongata,  and  traceable  back  to  the  same 
tract  or  part  of  the  medulla.  In  the  anterior  tract  of  the  corpora 
quadrigemina,  a  root  of  the  optic  nerve,  coming  from  the  corpus 
geniculatum  internum,  terminates.  Small  nerve-cells  are  seen  in  the 
internal  gray  substance  of  the  quadrigeminal  bodies,  with  larger  mul- 
tipolar and  fusiform  ganglion  corpuscles,  the  latter  being  said  by 
Meynert  to  be  found  in  the  deeper  layers  of  the  anterior  bodies  about 
the  aqueduct  of  Sylvius.  The  functions  of  these  bodies  are  tolerably 
well  understood,  as  they  give  rise  to  the  optic  nerves  and  act  as  the 
ganglia  of  sight,  from  which  they  have  also  been  called  "  optic  gan- 
glia." Destruction  of  these  bodies  causes  complete  blindness.  They 
thus  serve  as  nervous  centres  for  the  perception  of  light,  and  a  reflex 
action  also  takes  place  through  them,  by  whiclj  the  amount  of  light 
admitted  to  the  eye  is  regulated  to  accommodate  the  sensibility  of 
the  pupil. 

The  structure  of  the  optic  thalami,  like  the  corpora  quadrigemina, 
consists  of  a  white  layer  overlaid  with  a  zone  of  nerve-fibres.  The 
posterior  end  of  these  ganglia  has  been  termed  the  pulvinar.  Inter- 
nally to  it,  and  more  posteriorly,  is  situated  the  corpus  geniculatum 
internum,  and,  externally,  the  corpus  geniculatum  externum.  Into 
the  latter  a  portion  of  the  optic  tract  passes  on  its  way  to  the  pul- 
vinar. Fusiform  cells  are  found  more  deeply  colored  than  those  of  the 
corpora  quadrigemina.     The  cells  of  the  corpus  geniculatum  exter- 


136 


PSYCHOLOGICAL   MEDICINE. 


num  are  found  to  be  frequently  pigmented,  and  the  internal  genicu- 
late body  also  contains  fusiform  cells.  The  thalamus  receives  numer- 
ous white  fasciculi  coming  from  the  hemispheres.  They  run  towards 
the  superior  surface  of  the  thalamus,  to  the  superior  and  internal 
border,  and  the  pulvinar,  and  are  ultimately  lost  in  the  same  manner 
as  are  the  fibres  continued  from  the  crus  cerebri  into  the  corpus 
striatum  ;  that  is,  by  a  subdivision  into  close  plexuses  of  extremely 
delicate  nerve-fibres.  The  functions  of  the  optic  thalami  have  been 
but  little  understood,  and  there  is  still  a  great  difference  of  opinion 
respecting  the  function  of  this  great  basilar  ganglion.  I  regard  it 
as  the  centre  of  general  sensibility,  and  it  is  certainly  a  fact  that 
all  the  sensory  fibres  go  to  terminate  in  the  optic  thalamus.  It 
would  seem  proper,  as  Luys  has  done,  to  subdivide  the  optic  thala- 
mus into  four  special  centres  or  ganglion  tracts.  Luys  considers 
that  the  optic  thalami  receive,  preserve,  and  transform  the  sensorial 
impressions  previous  to  their  definitive  irradiation  to  the  cortical 
periphery.  The  anterior  ganglion  tract,  he  considers,  is  undoubtedly 
connected  with  olfactive  impressions.  The  middle  ganglion  tract 
receives  the  nerve-fibres  of  the  second  pair,  and  may  properly  be 
called  the  optic  tract.  The  posterior  ganglion  tract,  from  its  connec- 
tion with  the- perception  of  sounds,  may  be  called  the  acoustic  tract. 
And  there  is  undoubtedly  another  tract  of  the  optic  thalamus,  which, 
from  its  close  relation  to  the  sensitive  fibres  of  the  convergent  sys- 
tem, may  be  called  the  tract  of  general  sensibility.  Ferrier,  who 
had,  as  a  result  of  its  destruction  experimentally,  produced  anaesthe- 
sia of  the  opposite  side,  held  it  as  a  centre  of  conveyance,  or  an 
interrupting  ganglion  of  the  sensitive  fibres,  through  which  might 
pass  all  the  fibres  of  the  sensory  nerves  which  have  their  origin 
beneath  the  cerebral  peduncles.  Crichton  Brown,  on  clinical  facts, 
regards  it  as  the  centre  of  general  sensibility.  Nothnagel,  in  his 
series  of  experiments,  has  not  found,  after  destruction  of  the  optic 
thalamus,  lesion  of  sensibility  or  of  voluntary  motility.  Meynert 
thinks,  as  the  result  of  anatomical  researches,  that  in  the  optic 
thalami  the  sensory  impressions  coming  from  the  periphery  are 
transformed  into  movements,  so  that  the  thalami  would  be  automatic 
centres  of  reflex  unconscious  movements,  and  would  also  stand  in 
some  relation  with  voluntary  movements.  Flourens,  Longet,  and 
Schiff,  as  a  result  of  experimental  research,  have  attributed  motor 
functions  to  the  thalami.  If  this  was  so,  and  especially  if,  as  has 
been  claimed  by  Lusanna  and  Lemoigne,  the  optic  thalamus,  with  its 


THE    HISTOLOGY   AND    FUNCTIONS    OF   THE    CEREBRUM.  l^f 

median  fascicles,  was  the  centre  for  movements  of  the  arm  and  hand 
of  the  opposite  side,  it  would  be  a  true  secondary  motor  centre, 
subordinate  to  the, psycho-motor  centres  of  the  cortex. 

The  structure  of  the  corpora  striata  consists  of  a  collection  of  gray 
matter,  nerve-cells,  and  of  fine  nerve-fibres.  They  contain  two  larger 
nuclei,  respecting  which  little  has  been  known,  and  it  is  only  lately 
that  we  have  subdivided  the  corpus  striatum  into  the  lenticular  and 
the  caudate  nucleus,  with  also  the  internal  capsule  and  its  function- 
ally distinct  sections,  which  were  pointed  out  by  Charcot.  The 
greatest  interest  attaches  to  the  corpus  striatum,  for  it  is  here,  as  I 
have  previously  remarked,  that  by  far  the  greater  number  of  cerebral 
haemorrhages  take  place,  giving  rise  to  the  typical  hemiplegia.  The 
system  of  nerve-fibres  is  derived  from  the  crura  cerebri,  running  par- 
allel in  a  straight  direction,  entering  both  nuclei,  and  ultimately  lost 
in  these  nuclei.  The  surface  of  the  corpora  striata  is  gray,  and  in  the 
gray  matter  we  observe  multipolar  ganglion  cells  and  smaller  cells. 
The  neuroglia  is  analogous  to  the  neuroglia  of  the  cortex  of  the 
cerebrum.  There  is  also  another  set  of  fibres,  proceeding  probably 
from  the  medullary  substance  of  the  hemispheres,  which  ramify  in 
the  large  nucleus  of  the  corpus  striatum.  These  fibres  differ  from 
those  derived  from  the  crus  cerebri,  which  in  this  location  are  ex- 
tremely attenuated  and  present  a  plexiform  arrangement.  Physiolo- 
gists in  the  past  have  supposed  the  functions  of  the  corpus  striatum 
to  have  some  connection  with  sensation  and  volition,  although  they 
have  not  attempted  to  explain  the  nature  of  the  connection.  As 
experimental  observations  have  proved  that  destruction  of  the  corpus 
striatum  results  in  motor  paralysis,  with  the  preservation  of  intelli- 
gence, depending  on  the  extent  of  the  lesion  ;  and  also,  as  cases  have 
occurred  in  which  the  functions  of  the  corpus  striatum  having  been 
not  destroyed,  but  impaired  by  compression  or  degeneration  of  its 
elements,  there  have  resulted  disturbances  in  the  motor  sphere,  may 
we  not  reasonably  infer  that  the  corpora  striata  are  undoubtedly  the 
centre  of  the  reception,  regulation,  and  elaboration  of  voluntary 
motor  impressions  emanating  from  the  deep  layers  of  the  cortical 
matter  whose  large  cells  originate  them  ?  Such  is  the  conclusion  of 
Luys,  and  it  is,  I  think,  the  correct  one,  judging  from  my  own 
researches  and  observations. 

There  is  no  question  more  interesting  to  the  student  of  mental 
pathology  than  that  of  the  connection  between  nerve  function  and 
nerve  organization,  and  it  is  only  by  the  better  knowledge  of  the 


138  PSYCHOLOGICAL    MEDICINE. 

physiological  laws  of  the  brain  that  we  can  determine  that  connec- 
tion ;  and  it  is  only  by  patient  experiment  and  observation  that  we 
are  to  fully  understand  the  nature  of  the  relation  between  the  his- 
tology of  the  brain  and  the  physical  functions.  It  is  impossible  to 
fully  appreciate  the  pathological  changes  met  with  in  the  brain  until 
we  are  in  full  possession  of  all  the  available  knowledge  of  cerebral 
histology  and  of  the  knowledge  of  the  normal  functional  activity  of 
nerve-cells,  and  we  certainly  cannot  understand  defective  intellect 
unless  we  are  thoroughly  acquainted  with  the  ordinary  and  normal 
manifestations  of  intellect.  We  must,  therefore,  clearly  understand 
the  physiological  laws  of  healthy  mental  action  before  we  can  com- 
prehend any  departure  from  the  healthy  working  of  such  laws.  With 
this  end  in  view  have  my  efforts  in  the  direction  of  the  study  of  the 
physiology  and  pathology  of  the  central  nervous  systems  been 
made. 

With  respect  to  the  functions  of  the  cerebrum  we  should  remem- 
ber that  we  can,  in  early  life,  direct  the  growth  of  function.  Dr. 
William  B.  Carpenter,  of  England,  in  writing  on  "  The  Hereditary 
Transmission  of  Acquired  Psychical  Habits,"  says:  "It  is  when  the 
brain  is  growing  that  the  direction  of  its  structure  can  be  most 
strongly  and  persistently  given  to  it.  Thus  the  habits  of  thought 
come  to  be  formed  and  those  nerve  tracts  laid  down  which  (as  the 
physiologist  believes)  constitute  the  mechanism  of  association,  by  the 
time  that  the  brain  has  reached  its  maturity ;  and  the  nutrition  of  the 
organ  continues  to  keep  up  the  same  mechanism  in  accordance  with 
the  demands  upon  its  activity,  so  long  as  it  is  being  called  into  use. 
Further,  during  the  entire  period  of  vigorous  manhood,  the  brain, 
like  the  muscles,  may  be  taking  on  some  additional  growth,  either  as 
a  whole  or  in  special  parts,  new  tissues  being  developed  and  kept 
up  by  the  nutritive  process  in  accordance  with  the  modes  of  action 
to  which  the  organ  is  trained ;  and  in  this  manner  a  store  of '  impres- 
sions '  or  '  traces  '  is  accumulated,  which  may  be  brought  within  '  the 
sphere  of  consciousness  whenever  the  right  suggesting  strings  are 
touched.'  " 


THE    PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.  1 39 


CHAPTER  X. 

THE    PATHOLOGY   AND    MORBID    HISTOLOGY    OF    ACUTE    AND    CHRONIC 

INSANITY. 

OPHTHALMOSCOPIC   APPEARANCE   AND    EXAMINATION   OF    BLOOD   AND    URINE. 

Membranes,  Epithelium,  Nerve-cells,  Nerve-fibres,  Special  Morbid 
Conditio7is  of  Gray  Matter,  etc. — The  morbid  histological  changes 
occurring  in  insanity  are,  at  the  present  day,  undergoing  microscopi- 
cal investigation  at  the  hands  of  many  very  skilful  observers,  both  in 
our  own  country  and  in  Europe,  and  these  assume  great  importance 
when  we  reflect  upon  the  fact  that  the  pathological  phenomena  dis- 
covered in  the  brains  of  persons  dying  insane,  all  have  for  their  basis 
interference  with  the  due  nutrition,  growth  and  renovation  of  the 
brain  cell,  which  by  interrupting  the  nutrition,  stimulation  and  repose 
of  the  brain,  essential  to  mental  health,  results  in  the  impress  of  a 
pathological  state  in  the  brain  and  disordered  mental  function.  The 
investigation  of  both  the  normal  and  the  morbid  histology  of  the 
brain  is  a  work  requiring  great  labor,  patience  and  perseverance,  and 
also  judgment  in  the  recording  of  observations;  and  even  by  the 
most  careful  and  conscientious  microscopists,  mistakes  may  be  made 
at  times  as  to  the  nature  and  value  of  appearances  met  with  in  histo- 
logical research.  We  may  fairly  divide  the  pathological  changes 
met  with  in  insanity  into  three  classes,  according  to  the  plan  of  M. 
Parchappe,  the  Inspector-General  of  Asylums  in  France,  who  has 
made  very  careful  and  thorough  investigations  : 

First.  Those  which  may  be  considered  accidental. 

Second.  Those  which  are  found  in  other  diseases,  yet  appear  to  be 
concerned  in  the  production  of  insanity. 

Third.  Those  essential  to  mental  disease. 

In  the  first  class  we  may  enumerate  cerebral  haemorrhages,  soften- 
ing of  the  white  substance,  and  disease  of  the  cerebral  vessels. 

In  the  second  class  we  meet  with  thickening  and  opacity  of  the 
arachnoid,  hyperasmia  of  the  pia  mater  and  of  the  brain,  serous  in- 
filtration of  the  pia  mater,  and  collections  of  fluid  in  the  arachnoid 
cavity. 

In  the  third  class,  or  the  changes  essential  to  mental  disease, 
we  find  sub-arachnoid  ecchymosis  and  a  partial  punctiform  injec- 


140  PSYCHOLOGICAL   MEDICINE. 

tion  of  the  cortical  surface,  with  or  without  softening;  extended 
softening-  of  the  middle  portion  of  the  cortical  substance;  adherence 
of  the  pia  mater  to  the  surface  of  the  brain ;  different  discolorations 
of  the  cortical  substance ;  loss  of  color  of  the  cortical  substance ; 
atrophy  of  the  convolutions  ;  and  lastly,  induration  of  cerebral  tissue. 

The  naked-eye  appearances  which  we  meet  with  in  the  bodies  of 
those  dying  insane,  are  chiefly  peculiarities  in  the  form  of  the  cra- 
nium, of  which  the  most  frequent  is  want  of  symmetry  between  the 
two  sides ;  the  shrunken  and  shrivelled  ear  in  chronic  insanity,  con- 
sequent upon  haematoma  auris ;  variations  from  the  normal  standard 
in  the  thickness  or  thinness  of  the  cranium ;  changes  in  the  mem- 
branes ;  and  finally,  changes  in  the  cerebral  substance  itself 

In  acute  insanity  the  changes  or  prominent  alterations  in  the  brain — 
as  will  be  seen  in  the  appended  cases  illustrative  of  the  pathology 
and  morbid  histology  of  insanity — met  with  by  the  writer,  have  been  : 
hyperaemic  conditions  of  the  brain  and  its  membranes,  which  latter 
are  often  thickened  and  opaque;  injection  and  softening  of  the  corti- 
cal substance  and  pigmentation  of  the  cortical  gray  substance. 
While  the  dura  mater  is  very  rarely  thickened,  its  vessels  are  found 
to  be  dilated  and  irregular,  and  the  coats  of  the  vessels  much  hyper- 
trophied.  The  arachnoid  I  have  found  to  be  thickened,  to  be  the 
seat  of  haemorrhage,  and  have  often  found  it  covered  with  fine  gran- 
ulations on  its  surface.  The  bloodvessels  of  the  brain  I  have  found 
to  present  thickening  of  the  coats,  thickening  of  the  sheath  or  hya- 
line membrane,  deposits  between  the  adventitia  and  sheath,  and  pro- 
liferation of  nuclei. 

The  neuroglia  has  been  found  to  be  the  seat  of  various  lesions  in 
insanity,  the  principal  of  which  are  disseminated  sclerosis  or  gray 
degeneration,  atrophy,  miliary  sclerosis  and  colloid  degeneration. 
The  cerebral  cells  have  been  found  to  be  the  seat  of  atrophy,  pig- 
mentary or  granular  degeneration,  calciferation  and  hypertrophy. 
In  chronic  insanity  the  changes  chiefly  met  with  in  the  brain,  have 
been  atrophy  of  the  convolutions  and  brain  itself,  induration  of  both 
white  and  gray  matter,  thickening  and  opacity  of  the  membranes, 
chronic  hydrocephalus,  effusions  into  the  sub-arachnoid  space,  pig- 
mentation of  the  cortical  substance,  and  extended  and  profound  scle- 
rosis of  the  brain.  The  pia  mater  is  found  to  be  thickened  and 
adhesive  to  the  brain,  and  its  vessels  tortuous  and  thickened  in  their 
walls.  I  have  also  noticed  atheromatous  and  fatty  degeneration  of 
the  walls  of  the  cerebral  capillaries. 


THE   PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.  141^ 

Having  devoted  considerable  time  and  thought  to  the  microscopic 
investigation  of  both  the  normal  and  morbid  histology  of  the  brain, 
I  desire  to  call  particular  attention  to  an  appearance  which  I  have 
noticed  in  the  brains  of  those  dying  insane,  and  to  which  my  atten- 
tion has  been  drawn,  from  the  interest  it  assumes  when  viewed  in  the 
light  of  the  probable  ultimate  cause  of  the  nutritive  defect  which 
results  in  chronic  insanity.  We  know  that,  for  the  proper  nutrition 
and  healthy  functional  activity  of  the  brain-cell,  is  required  the  pro- 
per nutrient  supply,  and  that  we  cannot  have  healthy  mental  func- 
tion without  a  due  supply  of  healthy  blood  to  normal  and  healthy 
brain-substance.  We  also  know  if  any  agent  operates  to  influence 
the  circulation  unfavorably,  so  that  a  morbid  condition  of  the  cere- 
bral capillaries  is  induced,  that  we  shall  inevitably  have  resulting 
morbid  changes  set  up  and  maintained  in  the  cerebral  cells.  In  pre- 
vious writings  on  insanity  I  have  called  attention  to  the  fact  that  a 
microscopic  examination  of  blood  from  insane  patients,  as  compared 
with  an  examination  of  blood  from  the  same  number  of  healthy  per- 
sons, revealed  in  the  blood  of  the  insane  a  marked  increase  in  the 
number  of  white  blood-corpuscles. 

In  making  microscopical  examinations  of  brain-tissue  from  chronic 
insanity,  I  have  noticed  repeatedly  in  different  cases  lymphoid 
cells  or  white  corpuscles,  and  also  red  corpuscles  in  small  numbers 
in  the  membranes  and  in  the  substance  of  the  brain  itself,  evidently 
having  emigrated  from  the  bloodvessels.  From  what  I  have  ob- 
served, I  think  that,  under  conditions  of  inflammatory  irritation  of 
the  brain,  an  emigration  of  lymphoid  cells  takes  place  on  a  large 
scale,  the  cells  or  corpuscles,  by  virtue  of  their  vital  contractility 
passing  through  the  walls  of  the  vessels  and  penetrating  into  the 
brain-tissue.  It  will  be  remembered  that  both  Dr.  Bastian  and  Dr. 
Blandford  have  noticed  a  plugging  up  of  the  bloodvessels  by  small 
embolic  masses  composed  of  aggregations  of  white  corpuscles  in 
insanity.  Ekker  found  that  the  vessels  of  the  gray  matter  were 
generally  dilated  in  insanity,  and  Ramaer  also  noticed  the  same  thing 
in  the  vessels  of  the  pia  mater,  while  Dr.  Major  has  described  a  di- 
latation of  the  arteries  in  "  brain  wasting,"  a  condition  which  apper- 
tains to  chronic  insanity.  We  have  here  two  factors  which  operate, 
I  think,  in  the  production  in  the  pia  mater  and  the  brain,  of  the  lym- 
phoid cells  and  in  some  cases  of  the  red  corpuscles;  first,  the  undue 
predominance  and  accumulation  in  the  bloodvessels  of  the  white 
corpuscles  which  obstruct  the  capillaries,  giving  us  as  a  result  an  im- 


142  PSYCHOLOGICAL    MEDICINE. 

peded  circulation  and  an  increased  pressure  in  the  coats  of  the  ves- 
sels ;  and  second,  the  dilatation  of  the  vessels  before  alluded  to. 
These  two  conditions  are  favorable  to  the  rapid  emigration  of  the 
white  and  the  red  corpuscles  through  the  walls  of  the  vessels ;  and 
also  perhaps  the  same  condition  may  be  produced  at  times  by  the  ob- 
struction in  the  capillary  vessels  becoming  great  enough  to  rupture 
them.  The  lymphoid  cells  must  act  undoubtedly  as  foreign  bodies  and 
a  slow  course  of  inflammation  is  set  up.  Such  an  inflammatory  pro- 
cess must  necessarily  be  of  slight  intensity  and  of  long  duration,  and 
these  collections  of  lymphoid  cells  undoubtedly  tend  to  become  de- 
veloped into  a  fibroid  structure,  resulting  in  the  induration  of  the  brain 
which  we  meet  with  in  chronic  insanit}-'.  I  am  also  forcibly  impressed 
with  the  idea  that  we  have  here  the  solution  of  the  problem  as  to 
the  relation  which  exists  between  tuberculosis  and  insanity.  Dr. 
Clouston,  in  the  Jownial  of  Mental  Science  for  April,  1863,  showed 
that  of  828  patients  who  died  with  tubercular  diseases  at  the  Royal 
Edinburgh  Asylum,  153  passed  rapidly  into  the  state  of  chronic  in- 
sanity, the  acute  stage  being  of  very  short  duration,  the  patients  all 
manifesting  a  decided  tendency  towards  chronicity.  He  also  noticed 
that  the  prognosis  relating  to  mental  recovery  was  eminently  unfa- 
vorable, and  that  apparent  recoveries  proved  to  be  only  remissions. 
In  these  cases,  where  the  development  of  the  two  diseases  seemed  to 
Dr.  Clouston  to  be  nearly  contemporaneous,  was  not  the  tuberculosis 
the  result  primarily  of  the  escape  or  emigration  of  the  lymphoid  cells 
into  the  connective  tissue  of  the  lungs  owing  to  this  state  of  leuco- 
cythaemia  in  the  patient  ?  I  think  that  this  condition  occurs  more  fre- 
quently than  we  are  aware  of,  especially  in  persons  who  inherit  the 
predisposing  neurotic  element  or  morbific  force.  That  there  exists 
such  an  hereditary  neurotic  or  morbific  element  or  force,  present  in 
both  insanity  and  phthisis,  I  most  firmly  believe ;  and  I  also  believe 
that  there  is  a  correlatmn  of  morbific  force  which  renders  these  dis- 
eases mutually  convertible.  I  have  repeatedly  seen  this  borne  out  by 
undeniable  facts,  children  of  one  family  being  affected  with  both  insan- 
ity and  phthisis  in  many  different  instances.  This  theory  that  "he- 
reditar}'  diseases  "  depend  on  a  correlation  of  morbific  forces  was  first 
advanced  by  Dr.  Winn,  of  London,  England,  in  1869,  in  his  treatise 
on  the  Nature  and  Treatment  of  Hereditary  Diseases,  zuith  Reference 
to  a  Correlation  of  Morbific  Forces. 

To  return,  however,  more  immediately  to  our  subject.     Respecting 
the  dilatation  of  the  vessels  which  I  have  before  alluded  to,  it  appears 


THE   PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.         1 45 

to  me  that  the  general  obstruction  in  the  capillaries  of  the  brain 
causes  primarily,  probably,  a  compensatory  hypersemia,  and  as  this 
gradually  becomes  permanent  the  small  arteries  would  naturally  be- 
come enlarged,  as  they  have  been  found  to  be  by  Ekker,  and  Dr. 
Major,  and  also  myself;  and  their  walls  would  become  thickened,  as 
we  find  them  to  be  in  post-mortem,  in  chronic  insanity.  Such  long- 
continued  mechanical  hyperaemia  causes  an  impairment  of  vitality 
and  function,  and  this  we  find  exemplified  by  the  retrogressive 
changes  which  occur  in  the  substance  of  the  brain  in  chronic 
insanity,  viz.,  atrophy,  induration,  and  degeneration  of  the  nervous 
elements  of  the  brain.  With  the  exception  of  cases  of  apoplexy  in 
which  large  clots  have  been  discovered  post-mortem,  I  am  not  aware 
that  any  observer  has  described  any  such  lymphoid  deposit  in  the 
brain,  which  may  or  may  not  have  undergone  fibroid  metamorphosis 
or  degeneration. 

I  think,  therefore,  that  from  both  a  physiological  and  pathological 
standpoint,  these  observations  become  of  the  highest  clinical  signifi- 
cance. (I  desire  not  to  be  misapprehended  as  regarding  the  presence 
of  the  lymphoid  deposits  in  the  brain  as  the  ultimate  cause  of 
insanity.)  I  do,  however,  think  that  by  their  presence  we  are  enabled 
to  explain  many  of  the  changes  incident  upon  chronic  insanity,  and 
think  their  presence  must  affect  very  materially  the  ultimate  molecu- 
lar changes  in  the  brain,  upon  which  its  functional  activity  depends, 
and  regard  it  as  a  very  strong  probability  that  such  foreign  deposits 
in  the  brain  may,  by  interfering  with  the  molecular  changes  just 
alluded  to,  destroy  both  functional  excitability  and  activity.  It 
would  appear  very  probable  that  the  prominent  alterations  taking 
place  in  chronic  insanity,  viz.,  atrophy  of  the  convolutions  and  of 
the  brain  itself,  and  induration  of  the  two  substances,  with  degenera- 
tion of  the  nerve-cells,  may  fairly  be  considered  to  depend  upon  this 
abnormal  relationship  between  the  blood  and  the  tissues,  which  be- 
comes the  ultimate  cause  of  the  nutritive  defect  which  results  in 
chronic  insanity. 

Ophthalmoscopic  Appearances  in  Insanity. — The  ophthalmic  appear- 
ance is  reported  by  Klein*  in  134  patients,  of  whom  42  were  affected 
with  general  paralysis,  19  with  mania,  19  with  epilepsy,  17  with  alco- 
holism, 4  with  apoplexy,  6  with  melancholia,  i  with  locomotor 
ataxia,  and  26  with  divers  forms.  In  89  cases  positive  results  were 
obtained,  which  he  divided  into  two  categories — one  of  3 1   and  the 

*  Wien.  Med.  Presse,  1877,  No.  3  (Abstr.  in  Central  Blatt.,  No.  29). 


144  PSYCHOLOGICAL    MEDICINE. 

other  of  58  cases.  In  the  first  class  Klein  found  9  times  retinitis,  8 
times  discoloration  of  the  optic  nerve,  6  times  atrophy,  and  8  times 
hyperaemia  of  the  retina.  The  second  class  consisted  of  29  congeni- 
tal anomalies  and  29  cases  of  a  peculiar  opacity,  resembling  the  senile 
metamorphosis  of  the  retina.  Since  this  change  was  found  in  18 
cases  out  of  42  of  general  paresis,  Klein  terms  it  retinitis  paralytica. 
During  an  epileptic  attack  he  observed  retinal  ischaemia  and  clonic 
spasm  of  the  iris.  The  conditions  of  the  retina  in  acute  dementia  and 
atonic  melancholia  are  those  of  anaemia,  the  optic  disks  being  pale, 
the  tint  of  the  choroid  being  lowered,  but  not  resembling  atrophy. 
In  atrophy  there  is  more  of  a  sharpness  and  brilliancy  of  pallor  than 
in  dementia  and  melancholia.  The  retinal  vessels  are  small  and 
shrunken,  but  no  trace  of  previous  tortuosity  is  apparent,  as  is  often 
seen  in  atrophy.  In  senile  atrophy  of  the  brain  the  cells,  through 
the  entire  depth  of  the  cortical  layer,  are  morbidly  affected ;  in  the 
larger  nerve-cells  the  process  is  one  of  granular  degeneration,  but 
in  the  smaller  cells  there  is  simple  atrophy  without  degeneration. 
The  nuclei  of  the  cells  are  degenerated,  and  ultimately  become 
destroyed ;  also  the  branches  of  the  large  cells  at  an  early  period. 
The  large  vessels  and  capillaries  are  dilated,  and  the  vascular  canals 
are  enlarged,  and  the  surrounding  cerebral  substance  is  indurated. 
The  fibres  are  abnormally  coarse  and  tortuous,  and,  in  some  parts, 
broken  down.  The  neuroglia,  which  includes  the  delicate,  almost 
homogeneous  matrix  supporting  the  nerve  elements,  is  in  a  state  of 
atrophy  and  degeneration,  and  the  corpuscles  increased  in  number, 
but  they  eventually  shrivel  and  atrophy.* 

Examinatioii  of  Blood  and  Urine. — A  microscopical  examination  of 
blood  from  insane  patients  as  compared  with  an  examination  of  blood 
from  the  same  number  of  healthy  individuals  revealed,  in  the  blood 
of  the  insane,  a  condition  of  leucocythsemia,  or  a  marked  increase  of 
the  number  of  white  corpuscles.  This  condition  has  also  been 
remarked  by  other  observers,  and  Dr.  Charlton  Bastian  and  Dr. 
Blandford  have  described  a  plugging  up  of  the  cerebral  vessels  by 
small  embolic  masses  composed  of  collections  of  white  corpuscles  in 
cases  of  acute  mania  and  delirium.  It  has  been  found  that,  during 
the  period  of  maniacal  excitement,  there  is  a  ma:rked  diminution  of 

*  Acute  cerebral  hypersemia  may  induce  a  congestion  of  tiie  optic  papilla.  I  have 
failed  to  find  in  mania,  melancholia,  and  dementia,  any  constant  reliable  changes  in  the 
eye,  while  in  general  paralysis  of  the  insane,  I  have  seen  atrophy  of  the  optic  nerve  fre- 
quently. 


THE   PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.  1-^5 

fibrin  in  the  blood,  and  during  convalescence  the  amount  of  fibrin 
is  increased  to  the  normal  standard.  These  results  have  been  con- 
firmed by  the  recent  researches  of  Hittorf,  Erlenmayer,  Michea,  and 
Dr.  Marcet.  Examination  of  the  urine  in  insanity  has  shown  that 
in  acute  mania  there  is  an  excessive  elimination  of  the  phosphates, 
as  a  rule,  while  in  dementia,  general  paralysis,  and  chronic  mania 
the  amount  of  phosphates  eliminated  is  generally  below  the  average. 
There  has  been  some  difference  of  opinion  in  different  observers  as 
to  the  reaction  of  the  urine  in  insanity,  Erlenmayer  claiming  that  it 
is  generally  alkaline  in  recent  cases  of  mania,  while  Dr.  Sutherland, 
who  has  paid  great  attention  to  the  condition  of  the  urine,  found  that, 
in  125  cases  of  recent  mania,  the  urine  was  acid  loi  times,  and  alka- 
line 13  times,  and  gave  a  neutral  reaction  once.  In  our  investigations 
we  have  found  the  reaction  to  be  acid  in  the  majority  of  cases  of 
those  affected  with  acute  and  chronic  mania  and  dementia.*  The 
small  amount  of  time  at  the  disposal  of  a  physician  in  charge  of  an 
institution  for  mental  diseases,  and  the  difficulty  of  making  an  ex- 
tended course  of  investigation  in  the  analysis  of  blood  and  urine 
which  is  so  desirable,  and  also  the  difficulty  of  making  microscopical 
researches,  are  causes  which  have  combined  heretofore  to  deter  the 
superintendents  in  this  country  from  giving  to  the  profession  the 
results  of  their  valuable  experience,  and  it  is  therefore  to  be  hoped 
that  the  time  is  not  far  distant  when  every  asylum  shall  possess  the 
services  of  a  skilled  pathologist  and  chemist. 

Dr.  J.  Batty  Tuke,  in  writing  on  the  morbid  histology  of  insanity, 
says  :  "  One  great  difficulty  which  presents  itself  to  the  mind  of  the 
cerebral  pathologist  is  to  determine  whether  the  morbidities  which 
are  apparent  on  microscopic  examination  are  of  a  primary  or  secon- 
dary nature;  whether  they  have  been  efficient  causes  of  insanity,  or 
whether  they  are  merely  the  results  of  malnutrition  of  the  brain,  and, 
as  such,  efficient  causes  of  chronic  lunacy.  There  exists  an  unde- 
termined point  in  anatomy  which,  until  settled,  must  leave  the  ques- 
tion, to  a  certain  extent,  open ;  that  point  is  the  presence  or  absence 

*  1  have  seen  the  most  intense  melancholic  depression,  associated  with  the  persistent 
presence  of  oxalate  of  lime  in  the  urine,  and  the  melancholia  has  rapidly  dissappeared 
upon  the  free  exhibition  of  the  dilute  nitro-muriatic  acid,  which  caused  a  disappearance 
of  the  crystals  of  the  oxalates  in  the  urine,  as  viewed  under  the  microscope.  In  cases  of 
languor,  depression,  and  melancholia,  with  perhaps,  slight  vertigo,  we  should  always  look 
for  the  oxalate  of  lime  with  the  microscope.  We  do  not  think  there  is  an  increased  quan- 
tity of  phosphates  in  the  urine  in  healthy  individuals  after  brain  work.  The  turbid  urine 
is  due  to  diminished  acidity. 

10 


146  PSYCHOLOGICAL    MEDICINE. 

of  cerebral  lymphatics.  When  it  is  considered  that  the  brain  is  an 
exceedingly  active  organ,  performing  many  and  various  functions, 
and  when  it  is  further  considered  that  it  can  obtain  no  vicarious  aid 
in  the  performance  of  those  functions, -^that  it  cannot,  like  the  lungs, 
seek  assistance  from  other  systems, — it  must  be  at  once  apparent 
that  the  question  of  its  possession  of  an  overflow  for  getting  rid  of 
superfluous  plasm  and  waste  products  is  of  paramount  importance. 
Fohman  and  Arnold  demonstrated  to  their  own  satisfaction  the  ex- 
istence of  a  system  of  lymphatics  in  the  pia  mater,  and  His,  Ober- 
steiner,  and  Boll  believe  that  the  pia  matral  envelope  of  the  cerebral 
arteries  (hyaline  membrane)  exercises  the  function  of  a  lymphatic 
duct.  The  ver}^  existence  of  such  a  sheath  or  envelope  has  been 
called  in  question,  but  comparatively  slight  study  is  needed  to  make 
its  demonstration  certain.  Although  differences  of  opinion  exist  as 
to  its  relations  and  manner  of  debouchment,  we  believe  that  it  ter- 
minates by  funnel-shaped  openings  into  the  spaces  which  exist  over 
the  sulci,  between  the  pia  mater  and  the  so-called  arachnoid  mem- 
brane. Kolliker  has  pointed  out  that  the  connection  between  the 
pia  mater  and  arachnoid  over  the  convolutions  is  so  complete  and 
perfect  that  only  in  parts,  namely,  over  the  sulci,  a  distinct  space  can 
be  shown  to  exist.  It  is  questionable  whether  the  arachnoid  should 
not  be  considered  to  be  merely  the  outer  layer  of  the  pia  mater.  In 
prosecuting  the  study  of  the  morbid  histology  of  the  brain  and  spinal 
cord  two  methods  of  investigation  should  be  adopted :  i.  The  ex- 
amination of  the  tissues  in  a  fresh  state.  2.  The  examination  of  the 
parts  in  situ  by  means  of  sections  made  after  submission  of  portions 
of  nervous  tissue  to  hardening  agents.  The  condition  of  the  con- 
stituents of  the  recent  brain  can  best  be  observed  by  coloring  small 
specimens  with  rosaniline.  The  modern  method  of  freezing  and 
section  by  means  of  the  microtome  designed  by  !Mr.  Bevan  Lewis, 
has  rendered  the  investigation  of  histological  brain  changes  a  com- 
paratively easy  task. 

The  Membranes. — The  dura  mater  is,  comparatively  rarely,  thick- 
ened by  proliferation  of  its  elements.  The  vessels  are  found  to  be 
irregularly  dilated  and  tortuous,  with  thickening  of  their  walls.  The 
arachnoid  and  pia  mater  are  in  such  close  anatomical  relation  on  the 
convexity  of  the  hemispheres  that  they  can  be  best  described  together. 
Between  them,  supported  by  a  delicate  connective  tissue,  lie  the 
bloodvessels,  which  dip  into  the  sulci,  carrying  with  them  an  invest- 
ment of  pia  mater,  which  gives  prolongations  to  accompany  them 


THE    PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.  I47 

when  they  pierce  the  cerebral  substance  and  form  the  so-called  hyaline 
membrane.  Over  the  sulci  are  the  spaces  usually  termed  subarach- 
noid, which  communicate  with  each  other  by  conduits  accompanying 
the  vessels.  The  microscopic  appearances  of  "  milky  arachnoid  " 
have  not  been  thoroughly  described.  Both  membranes  are  often 
thickened,  presenting  a  laminated  appearance,  and  the  connective 
tissue  supporting  the  bloodvessels  is  considerably  increased,  as  well 
as  the  pia  matral  prolongations  accompanying  the  bloodvessels  into 
the  cerebral  substance,  which  loses  its  hyaline  character  and  becomes 
distinctly  fibrous.  Extensive  but  thin  blood-clots  are  occasionally 
found  within  the  arachnoid  and  pia  mater,  while  more  rarely  extrava- 
sations of  blood  are  found  between  the  pia  mater  and  the  cerebral 
substance. 

Deposits  of  hsematoidin  often  surround  the  vessels,  and  their  coats 
are  frequently  hypertrophied.  Crystals  of  triple  phosphate  have 
been  seen  on  the  visceral  surface  of  the  pia  mater.  Lymph  has  been 
found  between  the  pia  mater  and  the  spinal  cord;  the  membrane  was 
thickened,  and  internal  to  it  were  numerous  distinct  laminae  of  a 
finely  fibrillated  material,  in  some  places  2oo"^h  of  an  inch  in  breadth. 

The  Epitheliian. — The  ground-glass  appearjince  frequently  seen  in 
the  ependyma  of  the  ventricles  is  due  to  three  different  morbid  con- 
ditions, which  are,  in  the  order  of  their  frequency,  proliferated  epi- 
thelium, lymph  exudations,  and  crystalline  deposits.  When  change 
in  the  epithelium  is  the  cause  of  the  granulations,  a  vertical  section 
shows  simply  a  proliferation  of  cells  projecting  into  the  ventricle  like 
villi. 

When  lymph  exudations  have  pushed  the  ependyma  upwards  it 
presents  the  appearance  of  rough,  irregular,  bulls-like  nodules,  con- 
sisting of  the  layer  of  proliferated  epithelial  cells  and  a  greenish, 
homogeneous  stroma,  which  together  overlie  the  pia  mater ;  the  same 
material  can  be  frequently  seen  infiltrating  the  subjacent  cerebral 
tissues.  Deposits  of  phosphate  of  lime  have  been  recorded  as  occur- 
ring beneath  the  ependyma  of  the  lateral  ventricles  in  general  paraly- 
sis, and  Bergmann  discovered  a  formation  of  pretty  large  crystals  of 
"  double  phosphate  "  in  both  plexus  choroidei  in  a  case  of  mania 
with  mental  weakness.  A  proliferation  of  the  columnar  epithelium 
of  the  central  canal  of  the  medulla  oblongata  is  not  unfrequent,  caus- 
ing its  occlusion. 

The  Nerve-cells. — The  changes  in  the  nerve-cells  are  most  marked 
in  the  anterior  two-thirds  and  superior  parts  of  the  hemispheres,  as 


148  PSYCHOLOGICAL    MEDICINE. 

in  this  situation  they  are  usually  most  numerous  and  large  in  size. 
In  the  depending  portions  of  the  hemispheres  and  the  occipital  lobe 
few,  if  any,  changes  have  been  noticed.  The  special  morbid  condi- 
tions of  the  nerve-cells  are :  a.  Atrophy,  or  pigmentary,  granular,  or 
fuscous  degeneration,  b.  Hypertrophy,  calcification.  Pigmentary, 
fuscous,  or  granular  degeneration  is  a  very  common  condition  in 
many  forms  of  insanity,  particularly  senile  insanity  and  general 
paralysis,  and  is  probably,  to  some  extent,  a  normal  senile  change. 
Dr.  Major  distinguishes  three  stages  :  i.  The  cells  lose  their  sharply- 
defined,  triangular  outline,  and  become  swollen  or  inflated  in  appear- 
ance; the  process  running  towards  the  periphery  of  the  convolution 
usually  remains  distinct,  but  the  other  processes  disappear  and  the 
cell  becomes  rounded  off;  the  nucleus  becomes  swollen  and  more  or 
less  round  or  oval,  and  the  nucleoli  are  seen  with  great  distinctness. 

2.  A  deposit  of  granules  takes  place,  either  external  to  the  cell  and 
pressing  upon  it,  or  in  its  interior,  until  it  becomes  more  and  more 
\'ellow  and  opaque ;  or  both  these  conditions  may  occur  together. 

3.  The  cell  goes  on  to  destruction,  breaking  down  and  shrinking, 
leaving  the  nucleus  surrounded  only  by  a  mass  of  granules,  and 
forming  a  gap  in  the  cerebral  tissue  formerly  occupied  by  the  swol- 
len cell ;  still  later  the  granules  entirely  disappear,  leaving  the  nu- 
cleus free.  He  has  not  observed  the  nucleus  actually  undergoing 
disintegration,  but  often  no  trace  of  it  is  to  be  found  in  the  mass  01 
granules  left  by  the  degenerated  cell.  Hypertrophy  of  the  large 
pyramidal  cells  of  the  inner  layer  has  been  observed  in  senile  atro- 
phy and  general  paralysis ;  as  the  name  implies,  they  are  large,  ab- 
normally distinct,  and  swollen  in  appearance,  often  presenting 
granular  masses  in  their  interior ;  the  processes  are  increased  both 
in  size  and  number ;  and  the  angles  of  the  cells  may  be  greatly  pro- 
longed, or  swollen  and  stunted.  Calcification  of  the  cells  by  the 
deposit  of  phosphate  of  lime  within  their  walls  has  been  observed, 
according  to  Blandford. 

Tlie  Nerve-fibres. — The  chief  changes  in  nerve-fibres,  apart  from 
their  disintegration  by  apoplexies,  softenings,  etc.,  are  coarseness, 
irregularity,  and  twisting  of  outline,  and  their  power,  in  the  fresh 
state,  of  resisting  pressure  under  a  covering-glass,  some  being  readily 
ampullated.  They  may  be  affected  by  a  pigmentary  degeneration 
similar  to  that  occurring  in  the  cells  ;  and,  finally,  they  may  present 
fusiform  or  oval  swellings,  which  tint  strongly  with  carmine,  and 
give  rise  to  the  appearance  known  as  amyloid  bodies. 


THE    PATHOLOGY   AND    MORBID    HISTOLOGY    OF    INSANITY.  1 49 

Special  Morbid  Conditions  of  ihe  Gi'ay  Matter. — In  many  subjects, 
when  the  pia  mater  is  thickened  and  hyperaemic,  a  condition  of  the 
gray  matter  closely  resembhng  gray  degeneration  in  the  white  mat- 
ter is  often  found  ;  it  differs  from  the  latter  by  the  absence  of  prolif- 
erated nuclei,  and  is  strongly  suggestive  of  lymph  infiltration,  which 
has  gradually  caused  atrophy  and  absorption  of  the  normal  struc- 
tures. Circumscribed  spots  of  yellow  softening  show  under  the 
microscope  ragged  fibres,  colloid  bodies,  and  granular  corpuscles  at 
the  base  of  the  diseased  tract.  Local  atrophies  of  the  convolutions 
are  pretty  common.  Under  the  microscope  a  thin  layer  of  indurated 
gray  matter,  presenting  no  trace  of  normal  structure,  may  be  found. 
In  other  cases  there  is  simple  absence  of  the  gray  matter,  the  white 
matter  in  both  being  unaffected. 

The  Neuroglia. — This  substance  undergoes  inflammatory  changes 
of  a  subacute  or  chronic  nature,  with  the  results  of  which  we  are 
familiar  as  more  or  less  diffused  sclerosis.  Together  with  the  other 
elements  of  the  cerebral  tissues,  it  undergoes  atrophy  in  the  brain 
wastings  of  senility,  and  especially  of  senile  dementia  ;  it  is  also  liable 
to  special  forms  of  degeneration,  which  have  been  called  miliary  scle- 
rosis and  colloid  degeneration,  though  those  terms  are  somewhat 
misleading,  as  the  changes  in  question  differ  entirely  from  those 
generally  described  by  these  names. 

General  Sclerosis  has  only  been  observed  in  one  case,  which  is 
fully  detailed  in  ^h^  Journal  of  Anatomy  and  Physiology,  May,  1873. 

Disseminated  or  Partial  Sclerosis,  or  Gray  Degeneration,  is  a  lesion 
frequently  met  with  in  the  brains  of  old-standing  cases  of  insanity, 
especially  in  general  paralysis.  Its  most  frequent  seat  is  the  white 
matter  of  the  motor  tract;  less  frequently  it  is  met  with  in  the  hemi- 
spheres. In  the  pons  varolii,  medulla  oblongata,  and  spinal  cord  of 
epileptics,  patches  of  this  disease  are  of  common  occurrence,  and  in 
an  extreme  degree.  When  a  fine  section  of  nerve-tissue  affected  by 
this  disease  is  examined  by  the  naked  eye,  circumscribed  opaque 
patches  can  be  seen ;  in  colored  sections  these  tracts  are  strongly 
tinted.  As  a  rule,  they  are  found  contiguous  to  a  vessel,  whose 
nuclei  are  much  proliferated  and  around  which  considerable  prolifer- 
ation of  the  nuclei  of  the  neuroglia  exists.  Under  the  microscope 
the  nerve-fibres  are  seen  to  be  partially  or  completely  atrophied  ; 
the  axis  cylinders  and  sheaths  are  destroyed,  and  the  field  is  occu- 
pied by  a  finely  molecular  and  fibrillated  material  imbedded  in  a 
cloudy,  homogeneous  plasm.     In  this  matrix  the  proliferated  nuclei 


150  PSYCHOLOGICAL    MEDICINE. 

exist,  somewhat  enlarged  sometimes,  slightly  granular  in  appearance  ; 
but  around  the  implicated  spot  they  are  to  be  seen  in  much  greater 
quantity  and  not  actively  diseased.  The  atrophied  nerve-fibres  occa- 
sionally project  raggedly  into  the  gray  matter,  where  they  are  lost. 
Rokitansky  believes  this  to  be  essentially  a  primary  increase  of  the 
neuroglia.  Leyden  thinks  it  occurs  secondarily  to  the  atrophy  of 
nerve-fibres,  while  Rindfleisch  and  others  are  of  opinion  that  the  first 
stage  is  marked  by  proliferation  of  the  nuclei  of  the  vessels,  which  is 
followed  by  an  increase  of  the  neuroglia  and  the  development  of  a 
morbid  plasm,  which  is,  in  all  probability,  modified  neuroglia. 

Miliary  Sclerosis. — For  the  full  details  of  this  remarkable  lesion 
the  reader  is  referred  to  the  Edinburgh  Medical  Journal  for  Septem- 
ber, 1868,  and  to  the  British  and  Foreign  Medico- Chirzirgical  Review, 
July,  1873.  The  following  is  a  short  account  of  its  principal  features: 
It  is  not  confined  to  any  one  class  of  mental  disease,  but  has  been 
found  best  marked  in  cases  accompanied  by  paralysis  or  epilepsy. 
It  differs  from  all  other  lesions  termed  sclerosis  in  not  being  preceded, 
attended,  or  followed  by  proliferation  of  the  nuclei ;  it  is  a  circum- 
scribed lesion,  occurring  in  patches  from  4'Q^th  to  ts^oo"^^^  of  an  inch 
in  length,  not  involving  surrounding  tissues  except  by  displacement, 
diffusing  no  morbid  plasm  beyond  its  own  area,  and  not  connected 
witli  the  bloodvessels.  It  is  essentially  a  disease  of  the  nuclei  of  the 
neuroglia,  and  its  progress  is  marked  by  three  stages  :  i.  A  nucleus 
becomes  enlarged  and  throws  out  a  homogeneous  plasm  of  a  milky 
color,  and  apparently  of  a  highly  viscid  consistence,  forming  a  semi- 
opaque  oval  spot,  usually  unilocular ;  but  by  aggregation  the  spots 
may  be  bilocular,  or,  more  rarely,  multilocular ;  in  the  centre  of  these 
spots  a  cell-like  body  containing  a  nucleus  is  discernible — the  origi- 
nal dilated  nucleus  of  the  neuroglia.  2.  The  morbid  plasm  becomes 
distinctly  molecular  and  permeated  by  fine  fibrils ;  as  it  advances, 
the  plasm  around  the  periphery  of  the  spot  becomes  more  dense  and 
a  degree  of  absorption  of  the  nerve-fibres  around  it  .takes  place. 
3.  The  molecular  matter  contracts  on  itself,  becomes  more  opaque, 
and  often  falls  out  of  the  section,  leaving  ragged  holes.* 

Colloid  Degeneration  may  be  either  a  primary  or  a  secondary  pro- 
duct; that  is  to  say,  there  is  reason  for  believing  that  in  certain 
forms  of  insanity  it  is  the  primary  pathological  change,  and  that  it  is 

*  The  reader  is  referred  to  the  micro-phctographs,  where  one  of  them,  marked  "sec- 
tion of  brain  from  case  of  chronic  insanity,  "  taken  from  a  case  of  homicidal  mania,  where 
there  was  suspected  epilepsy,  shows  this  lesion  very  markedly  in  the  third  stage. 


THE    PATHOLOGY   AND    MORBID    HISTOLOGY   OF    INSANITY.'      I5I 

also  to  be  met  with  in  the  brains  of  chronic  cases,  a  result  of  long- 
continued  perverted  vascular  action.  It  has  been  produced  artifi- 
cially in  the  brains  of  pigeons  by  incising  them  and  allowing  them  to 
heal.  This  degeneration  should  be  searched  for  in  recent  specimens. 
It  consists  of  round  or  oval  bodies  from  ^^'^o^h  to  ^oVc^^  of  an  inch 
in  diameter,  and  bounded  by  a  distinct  wall  containing  a  homoge- 
neous, transparent,  and  colorless  plasm  ;  sometimes  it  is  somewhat 
granular.  The  general  appearance  of  a  section  may  be  compared  to 
a  slice  of  cold  sago  pudding ;  it  cannot  be  colored  by  carmine. 
The  condition  may  be  regarded  as  a  degeneration  of  the  nuclei  of 
the  neuroglia,  and  is  found  in  both  gray  and  white  matter. 

The  Bloodvessels. — When  we  examine  an  injected  preparation  of 
the  substance  of  a  cerebral  convolution  and  witness  the  perfection 
and  delicacy  of  its  circulatory  apparatus,  and  when  we  reflect  on  the 
results  of  the  phenomena  of  congestion,  stasis,  and  anaemia  on  the 
functions  of  other  organs,  we  have  little  difficulty  in  comprehending 
the  influence  such  conditions  must  have  upon  the  highly  complex 
elements  which  make  up  the  organ  of  the  mind.  It  is  certain  that 
in  most  cases  of  recent  insanity  disturbance  of  the  cerebral  circulation 
is  one,  if  not  the  essential,  pathological  factor,  and  if  such  disturb- 
ance is  of  long  continuance,  permanent  lesions  of  cells,  fibres,  and 
nuclei,  and,  as  a  consequence,  chronic  insanity  in  some  form  must 
result.  The  examination,  therefore,  of  the  cerebral  vessels  is  of  pri- 
mary importance.  The  following  is  the  method  of  examination 
adopted  by  the  writer :  After  noting  the  degree  of  engorgement  or 
anaemia  in  the  centrum  ovale,  and  whether,  on  section,  the  vessels 
are  dragged  out  by  the  knife,  vessels  of  moderate  size  should  be  dis- 
sected out,  and  carefully  washed  with  camels-hair  brushes,  and  then 
submitted  to  the  microscope.  By  this  mode  of  procedure  the  follow- 
ing changes  may  be  discovered  : 

{a}j  Thickening  or  degeneration  of  one  or  other  of  the  coats. 
(^.)  Thickening  of  the  sheath  or  hyaline  membrane. 
((T.)  Deposits  between  the  adventitia  and  the  sheath. 
(<^.)  Proliferation  of  the  nuclei. 

(a.)  Thicke7iing'  or  degeneration  of  the  coats.  The  inner 
fibrous  coat  has  been  found  thickened  and  more 
fibrous  than  in  health.  The  musadar  coat  is  often 
hypertrophied,  especially  the  circular  fibres ;  it  is 
best  marked  in  general  paralysis  and  epilepsy.  The 
adventitia  is  occasionally  thickened.     The  whole  of 


152  PSYCHOLOGICAL   MEDICINE. 

the  coats  sometimes  undergo  a  hyaloid  or  vitreous 
change,  which  is  probably  allied  to  lardaceous  dis- 
ease.'^ 
(b.)   The  hyaline  mevibrane  or  sJieath  is  often  thickened  and 
fibroid,  enveloping  the  artery  in  a  loosely  sacculated 
manner.* 
(c.)  Deposits  between  the  adventitia  and  the  sheath  are  of 
two  kinds,  but  neither  is  peculiar  to  insanity,  being 
found  in  the  brains  of  persons  who  have  died  of  fever 
or  Bright's  disease  with  cerebral  symptoms.     The 
first  is  a  finely  molecular  material  of  a  pale  yellow^ 
tint,  or  more  often  colorless,  closely  resembling  in 
appearance    the    spores    of    the    favus    fungus,    and 
refracting   light    highly;    it    undergoes    no    change 
when    treated  with    the   ordinary   oil    tests,  and    is 
found  in  the  smallest  capillaries.     The  particles  vary 
in   size    from   ^-g-'Q-Q-th  to   ^-^-^\h.  of  an  inch.      The 
second  form  of  deposit  consists  of  irregular  crystals 
of  hsmatoidin,  distributed   pretty  equally  over  the 
vessels,  except  at  the  bifurcations,  where  they  are 
aggregated, 
(d.)  Proliferation  of  tlie  «?/r/^7  usually  accompanies  prolifera- 
tion of  the  nuclei  of  the  neuroglia ;  they  do  not  seem 
to  increase  to  the  same  size  as  those  of  the  neuroglia, 
but  become  oval  or  irregular  in  shape. 
Fine  sections  of  hardened  tissues  are  necessary  for  the  demonstra- 
tion of  the  following  vascular  changes  : 
(d'.)  Abnormalities  in  direction. 

(/^)  Dilatation,  microscopic  aneurism,  and  apoplexies. 
(^.)  Perivascular  spaces, 
(/z.)  Syphiloma. 

The  sympathetic  ganglia  undergo  a  pigmentary  degeneration  in 
various  forms  of  cerebral  disease.  The  fact  of  Dr.  Tuke  being  one 
of  the  most  talented  of  cerebral  pathologists  will  account  for  the 
length  with  which  his  observations  have  been  cited. 

*  Both  of  these  appearances  will  be  found  typically  displayed  in  our  micro-photograph, 
showing  the  thickened  bloodvessel  in  the  thickened  and  infiltrated  pia  mater.  Prolifera- 
tion of  the  nuclei  is  also  seen. 


p 


Explanation  of  Plate  of  Microscopical  Sections  of 
Brain  and  Spinal  Cord. 

No.  I  is  a  section  of  the  normal  spinal  cord,  for  purposes  of  comparison  with  the  dis- 
eased cord  in  General  Paralysis. 

Xo.  2  depicts  the  microscopic  appearance  in  a  case  of  chronic  insanity,  with  the 
"cribriform"  appearance  of  the  brain,  produced  by  the  pushing  out  or  dilated 
condition  of  the  brain  tissue  by  dilated  blood-vessels  in  repeated  attacks  of 
cerebral  congestion. 

No.  3  represents  the  same  portion  (anterior  cornua)  of  the  cord  from  a  case  of  Syphilitic 
Insanity.     We  see  a  loss  of  the  nerve  cells  and  also  destruction  and  breaking 

up  of  the  nerve  substance. 

No.  4  also  represents  the  brain  with  attached  Pia  Mater,  from  a  case  of  chronic  mania. 
The  Pia  Alater  A  is  seen  to  be  thickened  and  infiltrated  while  the  brain  tissue 
exhibits  the  condition  of  the  brain  tissue  surrounding  blood-vessels,  resulting 
from  long-continued  congestive  dilatation  of  vessel. 

No.  5  represents  loss  of  nerve  cells  and  elements  in  posterior  column  of  spinal  cord. 
In  the  place  of  the  nerve  cells  is  seen  a  new  connective  tissue-like  substance, 
which  lies  imbedded  here  and  there  in  irregular  plates. 

No.  6  depicts  miliary  sclerosis  of  the  brain  in  a  case  of  chronic  insanity.  This  is  a 
disease  of  the  neuroglia  of  the  white  matter  of  the  brain.  This  microscopical 
section  represents  the  disease  in  its  third  stage,  when  the  molecular  matter  con- 
tracts on  itself,  becomes  more  opaque,  and  falls  out  of  the  section,  leaving 
ragged  holes.  Miliary  sclei'osis  is  a  circumscribed  lesion  not  in\olving  sur- 
rounding tissues. 


■'jatd  attac: 


'later,  fVc 


rs  im Close 


Plate  II. 


Micro-photographs  of  the  Brain  and  Spinal  Cord,  taken  by  the  author. 


ILLUSTRATIVE    CASES.  I  53 


CHAPTER  XI. 

CASES     ILLUSTRATING    THE    PATHOLOGY    AND     MORBID     HISTOLOGY    OF 

INSANITY. 

The  following  cases  are  some  of  those  in  which  I  have  had  an 
opportunity  of  making  a  post-mortem  examination,  and  will,  there- 
fore, be  of  practical  interest  to  the  profession  : 

Case  I.  Melaiicliolia  ivith  Delusions. — Death  resulting  from  chronic 
meningitis.  C.  McC,  male,  aged  44  years;  single ;  occupation,  porter. 
Upon  his  admission  to  the  asylum  he  was  noisy  and  maniacal.  The 
state  lasted  but  a  few  days,  and  he  then  became  depressed  and  mel- 
ancholy. He  refused  food  for  a  number  of  days  and  had  to  be  fed 
artificially.  The  melancholia  assumed  an  acute  form  and  he  had  hal- 
lucinations of  sight  and  hearing,  causing,  at  times,  great  terror  and 
mental  excitement.  At  such  times,  when  he  imagined  he  saw  devils 
in  the  ward,  his  face  would  assume  an  aspect  of  the  utmost  fear  and 
distress.  He  often  expressed  a  wish  to  commit  suicide.  He  died  quite 
suddenly  about  five  months  after  his  admission,  having  eaten  and 
slept  but  little  for  some  days  previous.  Post-mortem :  Upon  removing 
the  calvarium  the  dura  mater  was  found  to  be  adherent  to  it ;  the 
pia  mater  was  thickened,  infiltrated,  and  hyperaemic ;  the  arachnoid 
was  clouded  and  covered  with  granulations ;  the  brain  was  hyper- 
aemic and  the  cortical  substance  softened ;  the  lateral  ventricles  were 
filled  with  fluid;  the  lungs  revealed  commencing  tuberculosis;  the 
kidneys,  spleen,  and  liver  were  normal. 

Case  II. — M.  H.,  male,  aged  31,  single,  and  by  occupation  a 
laborer.  He  suffered  from  melancholia.  He  had  delusions  of  fear 
and  persecution,  and  suicidal  impulses.  Often  refused  food,  saying 
he  wished  to  die.  The  mental  faculties  were  very  feeble,  and  the 
enfeeblement  gradually  increased.  The  bladder  became  paralyzed 
and  the  health  gradually  failed  for  about  eight  months,  when  he  died 
from  exhaustion.  Post-mortem :  The  membranes  were  found  to  be 
adherent  to  each  other,  and  the  pia  mater  was  thickened  and  adhe- 
rent to  the  surface  of  the  brain.  Throughout  the  brain  were  small 
miliary  tubercles ;  the  substance  of  the  brain  was  softened  near  the 
base;  there  was  also  considerable  effusion  about  the  base  of  the  brain 
and  effusion  in  the  lateral  ventricles ;  lungs  normal ;  kidneys  con- 
gested; spleen,  liver,  and  heart  normal. 


154  PSYCHOLOGICAL    MEDICINE. 

Case  III.  Melancholia  zvith  Religions  Delusions  and  Hallucinations 
of  SigJit  afid  Hearing. — Death  resulting  from  acute  tuberculosis  and 
rupture  of  pulmonary  artery.  J.  S.,  aged  20,  single  ;  occupation, 
laborer.  Upon  admission  to  asylum  was  in  poor  physical  condition, 
having  never  regained  his  strength  since  an  attack  of  pneumonia 
some  months  previous.  There  was  dulness  at  the  apices  of  both 
lungs,  and  a  prolonged  expiratory  murmur,  with  difficult  respiration. 
He  was  very  much  depressed  and  melancholy,  and  said  that  he  had 
committed  unpardonable  sins  and  should  be  eternally  lost.  At  night 
he  imagined  he  was  visited  by  evil  spirits,  who  tormented  him.  He 
died  suddenly  five  months  after  admission  to  the  asylum  of  which  he 
was  an  inmate.  Post-mortem :  Dura  mater  firmly  adherent  to  the 
skull ;  the  meninges  were  congested  and  the  vessels  enlarged ;  the 
brain  revealed  softening  of  the  cortical  substance  and  effusion  of  fluid 
in  the  lateral  ventricles.  Examination  of  the  lungs  revealed  the  ex- 
istence of  tuberculosis.  The  upper  and  the  middle  lobes  of  the  right 
lung  were  partially  destroyed,  and  the  sudden  death  was  found  to  be 
the  result  of  rupture  of  the  upper  branch  of  the  right  pulmonary 
artery  in  the  middle  lobe  of  the  right  lung. 

Case  IV.  Dementia  and  Paresis. — Death  resulting  from  pulmo- 
nary haemorrhage.  T.  A.,  male,  aged  22  years,  single ;  occupation, 
wagon-maker.  Upon  his  admission  to  the  asylum  was  demented, 
with  symptoms  of  paresis.  Laughed  vacantly  when  addressed,  and 
stared  unmeaningly  about  him.  No  appreciation  of  condition  or 
surroundings.  His  gait  was  staggering  and  his  lips  and  tongue  were 
affected  with  muscular  tremors.  He  never  spoke  but  once,  and  that 
was  upon  the  occasion  of  a  visit  from  his  brother.  His  speech  at 
that  time  was  hesitating  and  trembling.  He  had  an  attack  of  sub- 
acute meningitis  four  months  after  his  admission,  and  died  three 
months  later  from  an  exhausting  haemorrhage  from  the  lungs.  Post- 
mortem :  The  membranes  were  found  to  be  adherent  to  the  skull ; 
there  was  subarachnoid  effusion  and  a  large  effusion  between  the  pia 
mater  and  the  brain ;  the  pia  mater  was  thickened  in  patches ;  there 
was  effusion  at  the  base  of  the  brain,  fluid  in  the  spinal  canal,  and 
the  spinal  cord  was  atrophied ;  there  was  a  miliary  tuberculosis 
throughout  the  brain.  Upon  making  an  examination  of  the  chest 
the  left  lung  was  found  to  be  partially  destroyed  by  the  breaking 
down  of  the  caseous  products  of  pneumonia,  as  a  result  of  which 
large  cavities  were  formed.  The  heart  gave  evidence  of  recent  endo- 
carditis.    The  surface  of  the  heart  and  endocardium  were  covered 


ILLUSTRATIVE    CASES.  155 

with  miliary  tubercles.  The  walls  of  the  heart  were  atrophied,  and 
exhibited  traces  of  fatty  degeneration.  The  kidneys,  spleen,  and 
liver  were  all  normal.  Upon  hardening  the  spinal  cord,  and  making 
thin  sections,  and  employing  carmine  staining,  there  was  found  to  be, 
upon  microscopical  examination,  atrophy  and  degeneration  of  the 
nerve-elements  of  the  posterior  columns,  with  increase  of  connective 
tissue.  Sections  of  hardened  brain-tissue  being  made,  there  was  ob- 
servable in  the  cerebral  cells  of  the  frontal  convolutions  (after  stain- 
ing) a  diffused  granular  degeneration  ;  also  diffused  collections  of  the 
lymphoid  cells,  alluded  to  previously,  most  of  which  had  undergone 
a  fibroid  metamorphosis.  No  change  could  be  detected  in  the  cells 
of  the  cervical  sympathetic,  which  was  carefully  examined. 

Case  V. — M.  A.  R.,  female,  aged  29,  single ;  occupation,  servant. 
Admitted  to  asylum  with  dementia,  which  ended  in  paresis.  Speech 
was  slurring  and  hesitating,  and  her  gait  was  staggering.  She  suf- 
fered from  gradually  progressing  paralysis,  which  involved  the  sphinc- 
ters of  the  rectum  and  bladder.  The  cutaneous  and  muscular 
sensibility  was  impaired,  and  there  was  loss  of  electro-muscular 
contractility,  so  that  disease  of  the  antero-lateral  and  posterior  col- 
umns of  the  spinal  cord  was  diagnosticated  before  death.  The 
paresis  was  attributed  to  spinal  injury  received  when  quite  young. 
She  died  from  exhaustion  four  months  after  her  admission  to  the 
asylum  of  which  she  was  an  inmate.  Post-mortem :  The  dura  mater 
was  firmly  adherent  to  the  cranium,  the  pia  mater  was  thickened  and 
infiltrated,  and  the  arachnoid  thickened  and  opaque.  The  convolu- 
tions of  the  brain  were  atrophied  and  the  brain-substance  indurated. 
There  was  fluid  in  the  spinal  canal  and  the  cord  was  slightly  atro- 
phied and  softened  in  patches.  The  uterus  was  in  a  rudimentary 
condition,  apparently  never  having  been  developed  properly.  The 
spinal  cord,  after  being  hardened  and  sections  made,  revealed,  upon 
microscopical  examination,  loss  of  neuroglia  and  connective  tissue, 
degeneration  of  the  posterior  columns,  and  loss  of  nerve-tubules  of 
white  substance.  The  ganglion  cells  of  both  anterior  and  posterior 
cornua  were  atrophied  and  disintegrated,  and  granular  and  fatty 
matter  occupied  their  place. 

Case  VI.  Dementia  and  Epilepsy. — Death  taking  place  after  a  suc- 
cession of  paroxysms.  O.  M.  S.,  male,  aged  19;  occupation,  gardener. 
Was  admitted  to  the  asylum  of  which  he  was  an  inmate  with  epilepsy 
associated  with  mania,  which  preceded  and  followed  the  paroxysms, 
requiring  sometimes  mechanical  restraint.     Dementia  soon  resulted 


156  PSYCHOLOGICAL    MEDICINE. 

from  the  mental  deterioration.  The  patient  had  epileptic  fits  nearly 
every  day,  which  condition  had  been  going  on  for  years.  He  also 
inherited  the  predisposition  to  epilepsy.  During  the  mania  he  imag- 
ined himself  to  be  the  Emperor  of  Germany.  The  paroxysms  in- 
creased in  frequency  and  intensity,  in  spite  of  all  medication,  for  eight 
months,  when  he  had  a  succession  of  fits  lasting  thirty-six  hours, 
during  one  of  which  paroxysms  he  died.  Post-nwrtejn :  Membranes 
of  brain  thickened  ;  arachnoid  and  pia  mater  thickened  ;  brain  atro- 
phied and  indurated  ;  lateral  ventricles  filled  with  fluid ;  spinal  cord 
normal.  Upon  hardening  the  brain-tissue  and  medulla  oblongata 
and  examining  microscopically,  there  was  seen  to  be  some  vascularity 
in  the  fourth  ventricle,  which  extended  through  the  medulla,  the  cap- 
illary vessels  of  which  were  somewhat  thickened  and  enlarged.  The 
cervical  sympathetic  was  also  subjected  to  a  careful  microscopical 
examination,  but  without  satisfactory  results. 

Many  more  interesting  cases  might  be  given,  but  want  of  space 
forbids.  In  closing  this  record  of  examinations  I  desire  to  insert  the 
post-mortem  appearances  of  a  very  interesting  case,  in  which  insanity 
and  phthisis  were  contemporaneous  in  their  development : 

Girl,  aged  23.  Dementia,  paresis,  tuberculosis.  Fost-mortcm : 
Pulmonary  tuberculosis,  with  cavities  at  apices  of  both  lungs.  Brain 
atrophied,  ansemic,  and  indurated,  being  the  result  of  the  lymphoid 
deposit,  as  proved  by  microscopic  examination.  Upon  hardening 
the  cord  the  posterior  sections  of  the  lateral  column  were  found  to 
be  affected.  The  posterior  column  presented  atrophy  and  disinte- 
gration of  nerve  elements  and  plates  of  connective  tissue  in  different 
places.  In  the  postero-lateral  columli  were  granular  and  fatty  cor- 
puscles and  new  bands  of  connective  tissue.  It  being  a  rather  diffi- 
cult matter  to  harden  the  very  delicate  tissue  of  the  brain  so  as  to 
be  enabled  to  cut  sufficiently  thin  sections  for  demonstrating  the 
finer  structural  relation  of  the  tissues,  the  writer  gives  the  formula 
employed  by  him  for  a  hardening  fluid  for  the  brain  and  spinal  cord, 
which  in  its  effects  surpasses  any  other,  and  better  prepares  the  tis- 
sues for  the  reception  of  staining  fluids.     It  is  as  follows : 

JJ.   Bichromate  of  ammonia,  .         ,  ..        .  .160  grs. 

Metliyl  alcohol, lo  oz. 

Distilled  water, 30  oz.     M. 


TREATMENT   OF    INSANITY.  1 5/ 


CHAPTER   XII. 


TREATMENT    OF    INSANITY. 


General  Principles — Necessity  of  Prompt  Treatment — Curability  of  In- 
sanity— Statistics  of  various  Asylums  and  their  Views  of  Treatment 
— Moral  Treatment — Food,  Work,  and  Amusements — Clinical 
Lectures  in  the  State  Hospitals  for  the  Insane — Mechanical  Re- 
straint—Maudsley  s  Viezvs — Dr.  Isaac  Ra/s  Views — Medicinal 
Treatment — Cases  Illustrating  Treatment. 

General  Principles. — The  indications  for  treatment  in  mental  disease 
are,  as  Dr.  Blandford  has  admirably  shown,  "  To  restore  to  health  the 
disordered  brain ;  to  cause  the  incessant  waste  to  cease ;  to  promote 
a  storing  and  not  an  expenditure  of  nerve-force.  The  brain  must  be 
nourished  by  healthy  blood.  The  quantity  of  the  latter  when  in 
defect  must  be  increased ;  when  its  quality  is  in  fault,  it  must  be  im- 
proved, and  when  the  blood-flow  is  in  excess,  it  must  be  checked ; 
while  all  causes  of  disturbance  reacting  upon  the  brain  from  other 
organs  of  the  body  must  be  removed.  Fresh  scenes  and  faces,  and 
the  cessation  of  work  and  worry  will  often  effect  a  cure."  The  re- 
moval of  the  patient  suffering  from  mental  disease  from  his  imme- 
diate surroundings,  although  not  necessarily  to  an  asylum,  is  gene- 
rally necessary  for  his  cure,  as  the  outbursts  of  anger  and  the 
delusions  connected  with  those  nearest  and  dearest  are  antagonized 
by  the  moral  effect  of  the  change ;  and  if  the  case  is  promising  and 
early  treatment  adopted,  a  cure  will  probably  result.  As  a  rule,  pa- 
tients are  not  placed  promptly  enough  under  adequate  and  appro- 
priate treatment.  A  great  deal  of  painful  emotional  distress  is 
avoided  by  removing  the  patient  to  fresh  surroundings  as  quickly  as 
possible,  and  one  of  the  greatest  essentials  is  good  and  abundant 
food,  to  which  allusion  will  be  hereafter  made  in  this  chapter.  If 
the  patient  is  dangerous  to  himself  or  others,  a  well-regulated  public 
or  private  hospital  is  evidently  the  appropriate  place  for  him.  The 
tendency  of  nature  in  this  disease  is  to  restore  herself  to  the  normal, 
we  must  therefore  check  the  great  expenditure  of  nerve  material  and 
see  that  the  food  contains  as  far  as  possible,  and  in  a  readily  assimila- 
ble form,  all  the  materials  required  to  supply  this  waste.  We  must 
remedy  impaired  digestion,  build  up  the   nervous   centres,  regulate 


158  PSYCHOLOGICAL    MEDICINE. 

vitiated  secretions,  see  that  our  patient  gets  plenty  of  sunlight  and 
pure  air,  and  above  all,  our  patient  must  have  time  for  nature  to  build 
up  nerve-cells  capable  of  functional  energy.  If  many  patients  took 
no  medicine,  but  merely  submitted  themselves  to  hygienic  conditions 
and  surroundings,  and  took  the  necessary  rest  and  time,  during  which 
there  should  be  no  demand  upon  the  nervous  energies,  and  took  food 
suitable  for  their  nervous  centres,  nature  would,  I  think,  antagonize 
the  atonic  functional  state  of  the  whole  nervous  system,  in  many  in- 
stances, and  might  make  good  recoveries.  The  use  of  nerve-foods, 
dietetics,  and  hygiene,  and  above  all,  moral  treatment,  are  perhaps 
somewhat  underrated  in  the  treatment  of  diseases  of  the  mind, 
and  it  certainly  requires  a  good  deal  of  wisdom  to  know  when  not  to 
interfere  with  Nature  in  her  effort  to  restore  the  mental  equilibrium 
of  a  case  of  insanity.  Nature,  by  her  own  laws,  is  capable  in  some 
cases,  if  not  too  much  interfered  with,  of  disintegrating  and  recon- 
structing cellular  material  that'has  become  unfit  for  the  manifestation 
of  vital  phenomena,  and  restores  lost  psychical  as  well  as  physical 
force.  If  we  remedy  the  inadequate  nerve  nutrition,  which  is  the 
cause  of  the  cerebral  neurasthenia,  which  is  the  first  link  in  the  chain 
of  mental  disorder,  we  may  trust  to  time  and  nature  to  accomplish 
much  for  our  patient.  There  is  a  power  in  music,  color,  beauty,  to 
tranquillize  excitement,  reanimate  hope,  diffuse  joy,  and  dispel  per- 
version of  thought,  all  of  which  is  manifested  in  the  re-establishment 
of  sanity.  These  agencies  have  power  to  reach  consciousness  and 
overthrow  diseased  action. 

The  physician  should  be  the  counsellor,  companion,  and  friend  of 
the  patient  mentally  diseased,  and  he  will  certainly  have  to  exer- 
cise forbearance,  attention,  and  sleepless  watchfulness  towards  his 
charges  if  he  is  to  restore  order  where  there  is  mental  chaos.  The 
motive,  impulse,  and  conduct  of  the  patient  mentally  diseased  re- 
quire to  be  analyzed  by  the  physician  in  charge.  The  patient 
must  be  taught  to  discriminate  as  soon  as  possible  between  what  is 
sound  and  sane  and  what  is  diseased  and  abnormal,  and  the  mental 
and  moral  nature  guided  aright.  He  needs  the  highest  intelli- 
gence and  sympathy  of  his  physician,  whose  very  presence  should 
suggest  hope  and  cure,  as  much  as  he  needs  drugs  and  therapeutic 
agents.  In  the  treatment  of  mental  disease  it  is  as  important  to  reach 
the  external  senses  by  which  moral  agents  may  travel,  as  it  is  to  reach 
the  nutritive  and  assimilative  functions  which  may  convey  physical 
agents  into  the  system.     In  treating  those  who  inherit  their  insanity, 


TREATMENT    OF    INSANITY.  159 

we  should  remember  that  we  must  set  in  action  for  our  patient  new 
forces  to  counterbalance  those  already  set  in  action  before  them,  and 
so  find  a  new  equilibrium  for  our  patient,  so  that  he  is  once  more  in 
harmony  with  his  surroundings.  We  have  to  meet  the  potentiality 
of  force  in  these  cases  and  neutralize  or  counterbalance  it  by  setting 
some  new  force  in  action.  We  can  greatly  modify  inherited  tenden- 
cies, and  by  continuous  effort  other  forces  may  be  brought  to  bear 
upon  the  centric  nervous  system  until  a  radical  change  in  the  whole 
system  is  brought  about.  We  shall  have  to  teach  our  patient  very 
often  to  conquer  his  lower  impulses,  and  to  struggle  with  natural 
tendencies  so  as  to  diminish  their  effect  upon  his  mental  nature,  and 
he  must  be  taught  to  reason  as  to  the  ultimate  consequences  of  his 
conduct. 

The  theory  of  localization  of  brain  function  does  not  throw  as 
much  light  as  we  could  wish,  or  lead  to  much  practical  benefit  in  the 
treatment  of  cerebral  diseases.  In  treating  such  diseases  we  must 
look  upon  the  brain  as  a  whole,  and  our  medicines  must  be  calcu- 
lated to  act  upon  it  through  the  general  system.  Even  when  we 
can  localize  we  have  to  combat  disease  of  the  brain  by  therapeutical 
measures  acting  upon  the  whole  of  the  cerebral  structure.  Gout  and 
syphilis  often  give  rise  to  cerebral  disturbance  of  an  obscure  nature. 
In  the  former  case  a  gouty  affection  of  the  joints  may  throw  light 
on  the  diagnosis  ;  or,  if  the  urine  is  carefully  examined,  chemically 
as  well  as  microscopically,  its  undue  acidity  or  the  presence  of  uric 
acid  crystals  may  afford  assistance  in  diagnosis.  In  the  latter  case, 
where  the  cerebral  phenomena  are  obscure  and  perplexing,  the  lib- 
eral and  continued  use  of  iodide  of  potassium  and  protiodide  of  mer- 
cury (the  latter  in  small  doses)  will  often  relieve  the  symptoms  and 
clear  up  the  doubtful  diagnosis.  I  think  the  effects  of  constitutional 
syphilis  in  the  brain  often  consist  in  gummatous  deposits  in. the  dura 
mater  or  in  the  brain  itself,  and  these  melt  away  under  the  combined 
influence  of  mercury  and  iodine.*     Both  the  alvine  and  renal  excre- 

*  Moxon  and  Broadbent  have  shown  that  syphilis  attacks  the  surface  of  the  brain  and 
its  membranes.  It  attacks  them  in  limited  spots  and  it  spreads  slowly.  The  morbid 
changes  are,  on  the  one  hand,  adhesion  of  the  membranes  to  each  other  and  to  the  surface 
of  the  brain,  by  means  of  an  exudation  which  may  invade  and  destroy  the  gray  matter,  in- 
terfere with  the  supply  of  blood,  and,  when  it  occupies  the  membranes  at  the  base  of  the 
brain,  surrounds  and  involves  the  nerves  in  the  intracranial  part  of  their  course ;  or,  the 
syphilitic  deposit  may  take  the  form  of  a  gummy  tumour.  The  brain  or  spinal  cord  may 
be  invaded  by  gummatous  tumors  springing  from  the  dura  mater,  or  from  bones,  or  there 
may  be  syphilitic  disease  of  the  walls  of  cerebral  vessels.     When  we  find  syphilomata  in 


l60  PSYCHOLOGICAL    MEDICINE. 

tions  should  be  examined  with  care  in  mental  disorders.  They  are 
rarely  found  normal  as  regards  quantity  and  quality.  The  bowels 
are  constipated  or  the  stools  are  wanting  in  bile,  although  diarrhoea 
is  present.  The  urine  is  very  seldom  in  a  natural  state.  It  is  thick 
and  turbid,  of  a  high  specific  gravity,  and  abounds  in  the  salts  of 
urea.  In  cases  of  melancholia  the  urine  contains  oxalic  acid  or  ox- 
alate of  lime  crystals.  The  body  is  poisoned  by  the  retained  nitro- 
genous material,  and  we  must  primarily  rid  our  patients  of  all  such 
substances.  This  can  be  effectually  done  by  administering  ten  grains 
of  calomel,  followed  by  salines,  which  prepares  the  system  for  other 
treatment.  The  administration  of  nitro-muriatic  acid,  in  water,  after 
m'eals  will  speedily  rid  the  nervous  system  of  the  poisonous  effects 
of  the  oxalate  of  lime  if  it  is  found  to  exist  in  the  urine,  and  I  have 
seen  the  most  intense  depression,  bordering  on  an  attack  of  mania, 
speedily  cured  by  relieving  the  oxaluria  which  had  caused  this  state 
of  melancholia. 

The  Necessity  of  Prompt  Treatment. — Although  it  is  not  generally 
so  regarded,  insanity  is  one  of  the  most  curable  of  serious  diseases  if 
promptly  cared  for  and  treated.  The  mistake  which  is  committed 
every  day  by  foolish  friends  and  relatives  of  keeping  secret  as  long 
as  possible  the  fact  of  the  patient's  insanity,  thereby  depriving  him 
of  the  necessary  care  and  treatment  at  the  outset  of  the  disease,  is 
often  fatal  to  the  prospects  of  recovery  of  the  unfortunate  patient, 
who  is  only  sent  to  an  asylum  when  he  has  become  perfectl}^  unman- 
ageable and  the  disease  has  become  deeply  seated.  It  has  been 
stated  by  eminent  authority  that  if  persons  who  are  attacked  by 
this  disease  were  cared  for  as  promptly  as  if  they  were  suffering  from 
an  attack  of  dysentery  or  fever,  eighty  or  ninety  per  cent,  could  be 
restored  to  health  and  usefulness.  There  is  no  disease,  however, 
which  develops  more  rapidly  if  not  treated,  and  tends  to  induce 
organic  degeneration,  which  renders  it  incurable.  From  a  financial 
point  of  view  it  pays  well  to  restore  the  insane  as  soon  as  possible  to 
usefulness  and  health,  and  thereby  save  the  commonwealth  the  cost 
entailed  by  the  loss  of  his  labor,  and  also  the  amount  that  has  to  be 
paid  for  his   board   and  clothing,   which,   at   the    lowest   estimate, 

the  brain,  they  are  usually  located  in  the  gray  matter  of  the  corpora  striata  and  thalami. 
I  have  seen  convulsions,  paralysis,  and  the  most  varied  intellectual  and  moral  distur- 
bance, from  syphilitic  disease  of  the  surface  gray  matter  of  the  brain.  We  may  have  syph- 
ilitic epilepsy,  cerebral  disease  in  infantile  syphilis,  and  syphilitic  thrombosis  of  cerebral 
arteries.  Headache  and  giddiness  are  prominent  symptoms  of  cerebral  syphilis,  with 
great  intellectual  dulness  and  muscular  weakness. 


TREATMENT    OF    INSANITY.  -■*        l6l 

amounts  to  not  less  than  ^^156  per  year,  or  I3  per  week.     Dr.  Ed- 
ward Jarvis,  of  Dorchester,  Massachusetts,  who  has  made  very  labo- 
rious investigations    upon    the   subject,   in   a  paper  entitleed  "The 
Political  Economy  of  Health,"  presents  the  following  view  of  the 
gain  or  loss  entailed  upon  the  State  or  family  of  an  insane  man  by 
his  cure  or  by  his  remaining  a  lunatic  for  the  period  of  life  left  to 
him  after  his  attack.     According  to  Mr,  John  L.  Copeland's  table, 
showing  the  average  longevity  of  the  insane  from  any  given  age,  it 
is  seen  that  a  man  of  20  years  of  age,  if  sane,  has  an  average  life  of 
39.48  years,  while  if  insane  he  has  but  an  average  life  of  21.31  years 
if  not  restored  to  health.    Dr.  Jarvis  has  estimated  that,  leaving  out  of 
sight  the  ten  or  twenty  per  cent,  of  the  insane  who  are  incurable,  the 
average  time  for  restoring  to  health  the  insane  who  apply  for  treat- 
ment upon  the  early  symptoms  of  disease  is  twenty-six  weeks.     At 
$4  per  week,  which  was  the  average  cost  in  the  three  State  lunatic 
asylums  in  Massachusetts  for  the  past  year,  this  amounts  to  ^104,  to 
which  is  added  ^30  for  each  patient  for  the  cost  of  rent,  or  interest 
on  the  value  of  the  hospital,  etc.,  for  six  months,  making  an  average 
cost  of  1 1 34  for  restoration  to  health.     If  not  restored  to  health,  the 
family  or  State  must  be  at  an  expense  of  ^156  a  year  for  21.31  years, 
and  must  also  lose  the  patient's  earnings  for  the  39.48  years  which 
he  would  have  made  if  well.     The  cost  of  the  patient's  support  is 
estimated  at  ^2121,  while  the  loss  of  his  future  labor,  if  he  becomes 
insane  at  20  years  of  age,  is  estimated  at  ^2665.37,  making  a  total 
loss  of  ^4786.37  if  not  cured,  while,  if  cured  in  the  average  time  of 
twenty-six  weeks,  at  a  cost  of  ^134,  there  will  be  a  gain  to  the  family 
or  to  the  State  of  ;^4652.     The  foregoing  is  an  admirable  argument 
for  sending  insane  patients  to  be  treated  in  the  early  and  curable 
stage  of  the  disease,  and,  if  acted  upon,  would  reduce  by  a  large  per- 
centage the  incurable  cases  which  are  now  to  be  found  in  such  great 
numbers. 

In  ancient  times  the  insane  were  regarded  as  possessed  with  devils, 
and  were  accordingly  fastened  with  chains,  handcuffs,  and  fetters,  and 
confined  in  cages  or  dungeons  to  drag  out  their  miserable  lives  as  best 
they  could.  In  1689,  Johannis  Helfrici,  in  writing  on  insanity,  says: 
"  Sfevere  discipline — chains  and  stripes — to  cure  the  fury  and  depress 
the  elation  of  mind."  Formerly  the  miserable  insane  were  crowded 
together  pell-mell  and  without  any  distinction,  exasperated  by  the  bru- 
tal rudeness  of  their  attendants  and  subjected  to  the  vain  caprices  and 
arbitrary  orders  of  an  unfit  or  negligent  superior,  and  were  constantly 


1 62  PSYCHOLOGICAL   MEDICINE. 

in  a  state  of  agitation  and  continually  uttering  complaints,  lamenta- 
tions, and  loud  cries,  while  to-day  every  patient  enjoys  the  degree  of 
liberty  accordant  with  his  personal  security  and  that  of  others,  while, 
instead  of  being  shut  in  cells,  they  are  permitted  to  promenade  freely 
in  a  spacious  and  agreeable  inclosure,  taking  the  precaution  of  having 
attendants  employed  especially  in  watching  them,  while  exercise  and 
labor  are  fundamental  rules  in  treating  insanity  in  our  hospitals  for 
the  insane. 

Curability  of  Insanity. — As  I  have  just  stated,  insanity  is  a  curable 
disease  if  properly  treated,  but  experience  shows  that  very  often  the 
disease  has  been  permitted  to  become  permanently  fixed  before  it  is 
subjected  to  a  curative  process,  and  thus  the  proportion  of  incurables 
received  at  our  asylums  has  been  constantly  increasing  in  the  prog- 
ress of  years.  The  next  national  census  will  show  that  the  num- 
ber of  the  insane  in  the  United  States  is  nearly  twice  as  large  as 
has  generally  been  supposed ;  and  in  the  State  of  Massachusetts, 
for  instance,  where  the  estimated  proportional  number  of  the  insane 
has  been  in  years  past  about  one  to  every  thousand  of  the  popula- 
tion, there  are  known  to  be  nearly  three  to  every  thousand.  We 
need,  what  we  are  beginning  to  have,  a  reformation  in  the  statistics 
of  insanity,  so  that  we  can  see  what  the  effects  of  treatment  and 
other  circumstances  are  on  the  health  of  patients  and  in  regard  to 
cure.  We  want  to  know  how  many  patients  recover  permanently 
or  for  a  long  period  of  time,  not  how  often  a  patient  discharged  from 
an  asylum  as  recovered  returns  to  the  same  asylum  to  be  again 
discharged  as  recovered  in  a  few  months.  A  great  many  cases  in 
our  State  hospitals  for  the  insane,  which  are  discharged  as  recovered 
in  the  course  of  any  given  year,  are  patients  who  have  previously 
recovered  from  earlier  attacks,  and  are  relapsing  cases,  nearly  all  of 
whom  will  probably  become  again  asylum  patients.  Even  among 
the  primary  recoveries  many  will  relapse.  I  think  there  is  no  rea- 
sonable doubt  of  the  fact  that  insanity,  as  it  is  seen  in  our  public 
institutions,  is  far  less  susceptible  of  cure  than  the  profession  has 
heretofore  been  led  to  believe.  All  readmissions  of  patients  to  asy- 
lums should  be  tabulated  by  the  superintendent,  as  it  is  only  in  this 
way  that  accuracy  respecting  true  recoveries  can  be  arrived  at.  One 
of  the  ablest  investigators.  Dr.  Pliny  Earle,  the  Superintendent  of 
the  Massachusetts  State  Lunatic  Hospital  at  Northampton,  in  his 
last  annual  report  of  that  institution,  gives  the  following  results  in 
1879-80,  at  the  ^Massachusetts  State  hospitals,  which,  as  relates  to 


TREATMENT   OF    INSANITY.  1 63 

the  curability  of  insanity,  has  an  important  bearing,  as  it  shows  the 
very  misleading  method  of  reporting  recoveries  which  almost  uni- 
versally prevails  in  our  public  institutions  : 

The  adoption  last  year  by  all  the  State  hospitals  for  the  insane  in  Massachusetts  of 
the  new  series  of  statistical  tables  prepared  by  tne  Board  of  Health,  Lunacy,  and  Charity, 
has  given  us  an  advantage  never  before  enjoyed.  It  has  enabled  us  to  show  very  nearly, 
if  not  positively,  just  what  was  done  by  those  institutions  in  the  course  of  the  official 
year  1879-80  towards  the  restoration  of  the  insane  and  the  diminution  of  their  number 
within  the  Commonwealth. 

At  the  four  State  hospitals,  at  Worcester,  Taunton,  Northampton,  and  Danvers,  in  the 
course  of  the  year  ending  with  September  30,  1880,  the  number  of  persons  admitted  was 
1092, — persons,  or  individuals,  be  it  understood,  because  it  not  infrequently  happens 
that  one  and  the  same  person  is  admitted  more  than  once  in  the  course  of  a  year.  Out 
of  this  number  of  persons,  and  those  who  were  in  the  said  hospitals  at  the  beginning  of 
the  year,  the  number  of  persons  discharged  recovered  was  283.  This  makes  the 
recoveries,  calculated  on  the  admissions — the  method  which  approximates  most  nearly 
the  truth — equal  to  25.91  per  cent.,  or  a  small  fraction  more  than  one-fourth  of  the 
whole. 

Such,  then,  are  the  results  for  one  year  at  our  curative  State  establishments.  I  have 
here  stated  them  in  the  way  that  similar  results  have  always,  prior  to  the  year  1880,  been 
reported  at  the  institutions  for  the  insane  throughout  the  United  States.  Even  as  so 
reported,  giving  to  them  all  the  advantage  derived  from  a  broad  general  statement,  with 
no  examination  into  the  detail  of  modifying  facts  and  conditions,  they  yield  no  evidence 
of  a  great  degree  of  curability  of  the  insane.  The  curable  three-fourths  of  former  faith 
dwindles  very  nearly  to  one-fourth  in  absolute  practice. 

The  hospital  at  Danvers,  the  newest  of  the  four  institutions  mentioned,  and  situated 
nearest  the  populous  centres  of  the  Slate,  received  nearly  all  of  the  recent  cases  from 
Boston  during  the  past  year.  It  probably  also  received  all  which  were  committed  from 
Lynn,  Salem,  Lowell,  and  Lawrence.  But  as  that  hospital  has  been  only  a  short  time 
in  operation,  I  disregard  it  in  the  showing  that  I  am  now  about  to  make,  and  take  the 
three  other  hospitals,  which  have  been  in  operation  different  periods,  varying  from  twenty- 
three  to  forty-eight  years. 

Those  three  older  hospitals,  at  Worcester,  Taunton,  and  Northampton,  admitted  during 
the  official  year  1879-80,  521  persons.  They  discharged  recovered  118  persons,  making 
a  percentage  of  recoveries  of  22.64,  ^  noteworthy  fraction  less  than  one-fourth  of  the 
number  admitted. 

But  let  us  look  a  little  farther.  The  three  hospitals  discharged  118  persons  recovered ; 
but  they  admitted  55  persons  whom  they  had  previously  discharged  recovered.  Conse- 
quently the  actual  gain,  in  the  course  of  the  year,  of  recovered  persons  in  the  commu- 
nity was  only  1 18  minus  55,  which  is  63.  This  is  only  12.09  P^'^  cent.,  or  less  than  one- 
eighth  of  the  number  of  persons  admitted.  It  is  an  average  of  21  gained  recoveries  at 
each  of  three  large  hospitals,  the  average  number  of  the  patients  of  which  was,  for  the 
year,  equal  to  503  for  each. 

A  fact  yet  unmentioned  gives,  at  first  view,  a  still  more  discouraging  aspect  to  the 
case.  The  55  persons  readmitted  after  previous  recovery  had  been  discharged  recovered, 
not  alone  once  each,  making  55  recoveries,  but  a  total  of  115  times.  The  public  had 
been  told  in  the  reports  of  115  recoveries  of  those  55  persons.  Hence,  if  recoveries,  and 
not  persons,  be  considered,  the  three  hospitals  issued   118;    but  they  took  back  115 


164  PSYCHOLOGICAL    MEDICINE. 

which  had  been  previously  issued,  leaving  in  the  general  population  a  gain  of  only  three, 
or  an  average  of  one  for  each  hospital. 

It  is  not  improbable,  however,  that  the  excess  of  recoveries  (115)  over  that  of  persons 
(55)  readmitted  was  counterbalanced  by  a  similar  excess  of  recoveries  over  that  oi persons 
(118)  discharged.  For  example,  if  one  of  the  55  persons  readmitted  had  previously  been 
discharged  recovered  five  times,  there  may  have  been,  among  the  118  discharged  recov- 
ered, one  who  had  previously  been  discharged  recovered  an  equal  number  of  times. 

The  statistics  just  given  in  aggregate  for  the  three  institutions  were  specifically,  for 
each  one  of  them,  as  follows  : 

At  the  Worcester  Hospital,  the  oldest  of  the  three,  although  its  present  building  is  the 
newest,  the  number  of  persons  admitted  was  222.  The  number  discharged  recovered 
was  41,  which  is  18.46  per  cent.,  or  less  than  one-fifth  of  the  admissions.  But  among 
the  admissions  were  25  persons  whom  it  had  previously  discharged  recovered.  Hence 
the  actual  gain  of  recovered  persons  outside  of  the  hospital  was  only  (41  minus  25)  16, 
or  7.2  per  cent,  of  the  number  admitted. 

The  25  persons  readmitted  had  been  discharged  recovered  a  total  of  58  times. 

At  the  Taunton  Hospital,  1S4  persons  were  admitted  and  49  discharged  recovered,  a 
percentage  of  26.62.  Of  those  admitted,  19  had  previously  been  discharged  recovered, 
so  that  the  gain  of  recovered  persons  in  the  general  population  was  only  (49  minus  19) 
30,  or  16.3  per  cent,  of  the  admissions. 

The  19  persons  readmitted  had  been  discharged  recovered  35  times. 

At  the  NorthanTpton  Hospital,  the  number  admitted  was  115.  The  number  discharged 
recovered  was  z8,  equal  to  25.22  per  cent.  But  of  the  persons  admitted  there  were  11 
who  had  previously  been  discharged  recovered.  The'  gain  of  recovered  persons  in  the 
community  was,  therefore,  only  (28  minus  11)  17,  or  14.78  per  cent,  of  the  number  ad- 
mitted. 

The  II  persons  readmitted  had  been  discharged  recovered  a  total  of  22  times. 

It  is  believed  that  from  this  exposition  it  will  be  apparent  that  the  method  still  almost 
universally  prevalent  of  reporting  recoveries  is,  except  in  a  technical  or  medical  sense, 
very  fallacious  and  deceptive ;  and  that,  until  some  other  method,  similar  to  the  new  one 
in  Massachusetts,  be  adopted,  those  statistics  will  be  worth  next  to  nothing  in  the  study 
of  the  problems  of  social  science. 

At  the  Danvers  Hospital,  the  number  of  persons  admitted  in  the  official  year  was  571. 
The  number  discharged  recovered  was  165,  or  28.89  ps'^  cent. 

The  proportion  of  recent  cases  received  at  that  institution  was  unquestionably,  and  for 
obvious  reasons,  larger  than  at  either  of  the  other  three. 

That  hospital  had  been  in  operation  less  than  eighteen  months  at  the  beginning  of  the 
official  year  in  question  ;  hence  it  could  not  be  expected  that,  among  the  persons  admitted, 
there  should  be  many  who  had  previously  been  discharged  from  it  recovered.  And 
yet  there  were  some  such  readmissions  the  report  does  not  state  how  many ;  but  it  was 
of  so  many  persons  that  their  total  of  recoveries  was  18. 

A  Glance  at  Great  Britain. — Having  shown  the  results  at  the  State  hospitals  of  Mas- 
sachusetts, perhaps  it  may  be  permitted  to  extend  our  observation  to  some  of  the  similar 
institutions  abroad,  for  the  purpose  of  further  illustrating  the  subject,  as  well  as  showing 
the  advantages  of  our  recently  adopted  method  of  reporting  recoveries. 

At  the  British  asylums  the  method  of  reporting  the  statistics  has  always  been  essen- 
tially the  same  as  it  is  in  the  United  States.  We,  indeed,  followed  their  example.  But 
it  has  heretofore  been  my  impression  that  the  proportion  of  patients  readmitted,  after 
having  been  discharged  recovered,  was  much  smaller  there  than  in  this  country.  I  have 
supposed  that  the  British  patients  remained  longer  in  the  hospitals  than   do  the  Amer- 


TREATMENT    OF    INSANITY.  '         165 

ican,  and  that  thus  their  recoveries  were  so  confirmed  that  relapses,  or  subsequent  attacks, 
were  comparatively  infrequent.  From  information  recently  received,  I  infer  that,  at  least 
to  a  certain  extent,  I  was  mistaken,  and  that  there  is  no  very  great  difference  in  these 
respects  between  the  two  countries. 

Dr.  Clouston,  of  the  Royal  Edinburgh  (Morningside)  Asylum,  in  his  report  for  18S0, 
has  introduced  tables  by  which  the  same  light  is  thrown  upon  his  statistics  of  recoveries 
as  upon  those,  of  the  Massachusetts  institutions  by  the  new  and  recently-adopted  method 
of  reporting,  with  the  exception  that  he  does  not  clearly  discriminate  between  cases  (or 
patients^  and  persons. 

The  admissions  at  Morningside,  in  1880,  were  347.  Of  these  patients,  the  number 
suffering  from  the 

First  attack  of  the  disease  was         .         .         .         ,         .         .         .         .231 

Second  attack,  ...........       58 

Third  attack,  ............       24 

Had  had  several  attacks,  .         ...         .         .         .         .         .         .26 

Congenital,      ............         8 

Hence  it  appears  that,  of  the  347,  no  less  than  108  (58  plus  24  plus  26),  or  nearly  one- 
third  of  the  whole,  were  readmitted  after  recovery  from  one  or  more  former  attacks. 

On  the  supposition  that  the  word  "several  "  means  three  (it  probably,  as  used  above, 
means  more),  those  108  patients  had  already  been  discharged  "  recovered  "  a  total  of  184 
times. 

So  much  for  the  patients  admitted. 

The  number  of  patients  discharged  recovered,  was  165,  which  is  47.55  per  cent.,  as 
calculated  "on  the  admissions.     Of  these  165,  there  were  who 

Recovered  for  the  first  time,     .         .         .         .         .         .         .         .         -97 

Had  recovered  in  former  years,        ;         .         .         .         .         .         .         .63 

Recovered  more  than  once  in  1880,         .         i         .....         5 

Total, 165 

At  the  close  of  the  year  no  less  than  nine  (9)  of  these  had  already  been  brought  back 
to  the  asylum,  and  still  remained  there  or  had  been  removed  tinrecovered. 

If  the  figures  in  these  two  tables  represent /f;'j£i/«.y,  we  derive  from  them  the  following 
result : 

The  asylum  discharged  recovered,  165  ;  but  it  took  back,  of  persons  who  had  formerly 
been  discharged  recovered,  108.  Consequently  the  actual  gain  of  recovered  persons  in 
the  general  population  was  only  57  (165  minus  108).  This  is  only  16.42  per  cent,  of  the 
admissions. 

The  movement  of  the  population  at  the  Morningside  Asylum  is  very  rapid.  Many  of 
the  patients  apparently  remain  in  the  institution  but  a  comparatively  short  time.  For 
these  reasons  it  is  believed  that  the  proportion  of  patients  returning  to  it  after  having 
been  discharged  recovered  is  larger  than  at  most  of  the  British  asylums. 

In  his  report  for  1880  of  the  Derbyshire  (England)  County  Lunatic  Asylum,  Dr.  J.  Mur- 
ray Lindsay  states  that  in  20  per  cent,  of  the  admissions  "  there  had  been  previous  attacks 
of  insanity."  At  the  Richmond  District  Asylum,  Dublin,  Ireland,  in  1880,  the  admissions 
were  420,  of  which  65,  or  15.47  per  cent.,  were  "relapsed  cases."     The  number  dis- 


1 66  PSYCHOLOGICAL    MEDICINE. 

charged  recovered  was  167 ;  but  the  gain  of  recovered  persons  in  the  general  population 
was  only  102  (167  minus  65). 

The  British  Medico- Psychological  Association. — The  most  striking  evidence  of  pro- 
gressive thought  relative  to  the  general  subject  under  consideration  is  the  fact  that,  at  the 
annual  meeting  of  the  British  Medico-Psychological  Association,  which  was  held  in  Lon- 
don in  August  last,  the  statistical  committee  of  that  society  recommended  for  adoption 
some  new  tables,  as  well  as  alterations  in  some  of  those  already  in  use,  so  modifying  the 
series,  as  a  whole,  that  the  statistics  of  the  asylums  can  be  reported  with  essentially  the 
same  detail  and  the  same  perspicuity  in  regard  to  recoveries  as  is  found  in  the  new  tables 
of  the  institutions  in  Massachusetts. 

After  a  brief  discussion,  it  was  decided  to  postpone  for  one  year  the  question  of  their 
adoption,  for  the  purpose  of  giving  the  members  an  opportunity  to  study  them  and  to  dis- 
cuss their  merits  at  the  quarterly  meetings.  But  there  can  hardly  be  a  doubt  as  to  the 
result.  The  proposed  alterations  will  be  adopted.  In  the  present  state  of  things — when, 
in  consequence  of  the  existence  of  various  organizations  for  the  promotion  of  the  objects 
of  social  science,  the  call,  outside  of  the  profession,  for  information  in  regard  to  insanity 
is  tenfold  greater  than  it  was  forty  years  ago — the  members  of  the  British  Association  can- 
not afford  to  refuse  to  display  their  statistics  in  such  manner  as  will  render  them  valuable 
to  the  members  of  those  organizations.  The  present  /if,^7z;nVfl/ truthfulness  of  those  sta- 
tistics must  be  expanded  into  an  absolute  truthfulness  in  regard  to  the  relation  between 
the  disease  and  individuals,  or  the  most  important  part  of  the  statistics  themselves  will 
soon  become  entirely,  as  they  even  now  are  essentially,  valueless.  Dr.  Clouston  is  not 
going  to  recede  from  the  position  gained  by  the  step  in  advance  taken  at  the  time  of  mak- 
ing the  report  just  passed  under  review, — a  position  in  which  he  could  show  not  alone 
what  his  institution  had  accomplished  during  the  year  in  relation  to  disease,  but  also  to 
what  extent  its  beneficial  influence  had  affected  his  fellow-vien.  There  are  many  others 
among  his  colleagues  in  the  specialty  in  England  and  Scotland  who  are  even  now  ready 
to  follow  his  example.  The  rest  will  doubtless  mostly  be  ready  at  the  expiration  of  the 
appointed  year.  Let  them  remember  that,  no  less  than  forty  years  ago,  a  reformation  in 
the  statistics  of  insanity  was  called  for  by  an  Englishman  whose  keen  and  comprehensive 
intellect  and  whose  soundness  of  judgment  were  second  to  those  of  no  one  of  his  coun- 
trymen who  have  written  upon  the  subject :  I  allude  to  the  late  Samuel  Tuke.  In  the 
thoughtful  and  excellent  article  used  as  an  introduction  to  his  translation  of  Dr.  Maxi- 
milian Jacobi's  treatise  on  the  construction  and  management  of  institutions  for  the  insane, 
he  wrote  as  follows  : 

"  The  whole  subject  of  the  mode  of  reporting  the  results  of  our  institutions  for  the 
insane  calls  loudly  for  attention,  if  we  would  arrive  at  any  useful  statistical  comparisons 
as  to  the  effect  of  treatment  and  other  circumstances  on  the  health  of  the  patients  and  in 
regard  to  the  cure  of  this  greatest  of  all  human  maladies.  The  subject  would  not  be 
unworthy  of  a  special  consultation  amongst  the  professional  men  who  are  devoted  to  this 
department  of  the  medical  art." 

It  appears  to  me,  from  the  very  wording  of  this  extract,  that  its  author  had  in  view  the 
specific  changes — perhaps  with  others — which  it  is  intended  to  accomplish  by  the  adop- 
tion of  the  proposition  now  before  the  Medico-Psychological  Association.  Shall  his  sug- 
gestions be  permitted  to  lie  under  the  dust  and  ashes  of  a  half  century  before  they  are 
carried  into  effect? 

Old  but  Valuable  German  Statistics.— Kt  the  Siegburg  Asylum,  in  Rhenish  Prussia, 
an  institution  which  at  that  time  was  under  the  superintendence  of  Dr.  Maximilian 
Jacobi,  the  statistics  of  recoveries  from  January  ist,  1825,  to  December  31st,  1845,  a 
period  of  twenty-one  years,  were  as  follows: 


79 

48 

127 

5 

6 

ir 

34 

30 

64 

39 

i8 

57 

43 

25 

68 

8 

4 

12 

TREATMENT    OF    INSANITY.  1 6/ 

Men.       Women.      Total. 

Whole  number  recovered, 377         284         661 

Living  at  the  end  of  the  period,  and  have  had  no  relapse,     169         153         322 
Relapsed  and  recovered  again  at  the  asylum,  . 

Relapsed  and  not  yet  cured, 

Relapsed  and  become  incurable,      .... 

Relapsed  and  died  insane,       ..... 

Died  without  a  relapse,   ...... 

Not  heard  from,       ....... 

The  number  of  patients  admitted  in  the  course  of  the  period  is  not  given,  and,  conse- 
quently, the  percentage  of  recoveries  cannot  be  obtained.  The  statistics  are  valuable 
chiefly  for  the  purpose  of  ascertaining  to  what  extent  the  recoveries  were  permanent. 

At  the  time  of  the  close  of  the  twenty-one  years,  259  of  the  661  persons  had  "  relapsed," 
or,  as  it  is  generally  stated  in  this  country,  had  had  a  second  attack.  This  is  equivalent 
to  39.1  per  cent.,  or  a  slight  fraction  less  than  two-fifths  of  the  whole.  But  these  are  not 
final  results.  Within  the  ten  years  next  following  the  close  of  the  period  the  number  of 
relapses  would  be  large,  especially  among  the  patients  who  recovered  in  the  last  half  of 
the  period.  If  about  ^z«;t>-fifths  of  the  whole  relapsed  within  the  period,  it  appears,  per- 
haps, more  than  probable  that  cK^-fifth  (or  half  as  many  more)  would  relapse  afterwards. 
Supposing  this  estimate  to  be  accurate,  the  whole  number  of  persons  relapsed  would  be 
equal  to  three-fifths  of  the  whole  number  of  persons  recovered.  This  corresponds  with 
Dr.  Thurnam's  well-known  formula,  derived  from  his  investigation  of  the  subsequent 
history  of  patients  recovered  at  the  York  Retreat. 

In  regard  to  the  proportion  of  the  persons  recovered  who  would  ultimately  die  insane, 
it  will  be  perceived  that,  at  the  close  of  the  period,  it  was  still  too  early  to  furnish  the  data 
for  a  very  accurate  estimate.  Something,  however,  in  that  direction  may  be  done.  Already 
the  number  who  had  relapsed  and  died  insane  was  57.  The  number  who  had  relapsed 
and  become  incurable,  and  who  would  consequently  die  insane,  was  64.  This  gives  a 
total  of  121,  or  a  little  less  than  o«f -fifth  of  the  whole,  whose  deaths,  while  insane,  were 
assured.  According  to  the  above-mentioned  formula,  two-Wi\hs  of  the  whole  should  die 
insane.  Hence  we  must  find  a  little  over  ^w^-fifth,  or,  in  actual  numbers,  143  inore  who 
would  die  insane.  These  must  be  looked  for  (i)  in  the  322  who  had  not  relapsed,  but 
many  of  whom  undoubtedly  would  relapse ;  (2)  in  the  127  who  had  relapsed  and  recov- 
ered again,  and,  judging  by  what  we  know  in  regard  to  the  liability  to  repeated  relapses, 
a  very  large  proportion  of  whom  would  relapse  again ;  and  (3)  in  the  1 1  who  had  relapsed 
and  were  not  yet  cured.  Of  these  460  persons  it  would  not  be  surprising  if  143  should 
die  insane. 

An  Echo  from  the  Antipodes. — There  are  two  lunatic  asylums  in  South  Australia. 
They  are  under  the  general  supervision  of  a  board  of  visitors,  of  which  Dr.  Alexander  S. 
Paterson  is  chairman.  The  report  for  1880  of  this  board,  signed  by  the  chairman  as  colo- 
nial surgeon,  is  before  me.  It  deals  with  the  subject  of  recoveries  with  a  commendable 
extent  of  detail,  although  it  fails  to  discriminate  between /ifr^t^wj-  and  cases,  and  to  give 
the  number  of  attacks  and  of  recoveries  of  those  patients  who  have  been  readmitted  after: 
recovery. 

At  the  two  asylums,  Adelaide  and  Parkside,  the  aggregate  number  of  admissions  in 
1880  was  223.  The  number  of  patients  discharged  recovered  was  90,  which  is  equal  to 
40.35  per  cent.  But  of  the  patients  admitted  there  were  35  who  had  previously  been 
discharged  recovered.  The  two  institutions  gave  to  the  people  90  recoveries,  but  they 
received  back  from  the  people  35  former  recoveries.  Therefore  the  gain  of  recoveries 
among  the  people  was  (90  minus  35)  only  55.     This  is  24.66  per  cent,  of  the  admissions. 


1 68  PSYCHOLOGICAL    MEDICINE. 

Five  of  the  patients  readmitted  returned  to  the  hospital  within  a  month  from  the  time 
at  which  they  were  discliarged  recovered. 

As  miglit  be  expected  in  a  country  so  recently  settled  as  South  Australia,  a  large  pro- 
portion of  the  recoveries  were  from  cases  originating  in  intemperance.  In  no  less  than 
25  cases  of  males  the  form  is  called  alcoholistnus.  The  patients  recovered  in  24  of  them. 
Eight  of  these  were  in  tire  asylum  less  than  a  month  each,  and  the  average  time  of  treat- 
ment of  the  24  was  only  one  month  and  seven  days. 

Athenian  Success. — I  now  approach  a  "  study  "  from  the  consideration  of  wliich  I 
would  gladly  be  released;  but,  in  the  discussion  of  this  subject,  it  is  proper  that  all  falla- 
cies should  be  exposed,  and  all  sources  of  error  pointed  out.  Furthermore,  I  have  been 
criticised  for  the  assertion,  in  the  pamphlet  on  the  Curability  of  Insanity,  that  the  medi- 
cal officers  of  institutions  for  the  insane  are  men  "with  like  passions  as  other  men,"  and, 
therefore,  the  introduction  here  of  any  evidence  that  sustains  the  truth  of  the  assertion  is 
more  than  justifiable. 

That  the  reader  may  enter  more  intelligently  upon  the  matter,  it  may  be  remarked  that, 
in  Ohio,  the  superintendents  of  the  State  institutions  for  the  insane  are  among  those  per- 
sons whose  offices  are  the  "  spoils  "  which  belong  to  the  victors  in  politics.  The  mere 
statement  of  this  fact  is  sufficient  for  the  present  purpose.  Any  attempt  to  present  in 
detail  the  evils  consequent  upon  such  a  state  of  things  would  be  irrelevant. 

In  his  report  for  1880  of  the  State  Asylum  for  the  Insane  at  Athens,  Ohio,  Dr.  H.  C. 
Rutter,  who  had  but  recently  been  appointed  to  the  office  of  superintendent,  mentions 
the  discussion  of  the  curability  of  insanity  begun  in  the  reports  of  this  hospital,  and,  after 
stating  that  it  has  been  taken  up  by  alienists  all  over  the  world,  gives  the  following  con- 
firmatory evidence  of  the  truth  of  one  of  my  "  conclusions :" 

"  It  has  frequently  happened  that  the  same  person  has  been  discharged  more  than 
once  during  one  year,  and  that  each  discharge  has  been  reported  as  a  separate  cure.  One 
person  in  Ohio  is  reported  to  have  recovered  seven  times  in  one  year,  and,  while  he  fig- 
ured in  the  annual  report  as  seven  '  recoveries,'  was  actually  a  patient  in  one  of  the  wards 
at  the  time  the  report  was  made  out." 

After  some  further  remarks,  he  proceeds  as  follows  : 

"  It  has  also  been  charged  that  these  '  cures '  are  flexible,  and  can  be  increased  by  the 
superintendent  whenever  occasion  arises  to  prove  his  superior  fitness  and  qualifications  as 
a  specialist.  This  charge  has  been  made  repeatedly,  and  by  many  distinguished  mem- 
bers of  the  profession,  who  have  been  disgusted  with  the  idle  talk  about  cures  made  by 
political  superintendents  for  the  purpose  of  gaining  cheap  notoriety  through  the  secular 
press.  We  have,  perhaps,  felt  this  in  Ohio  to  a  greater  extent  than  in  almost  any  other 
State  in  the  Union.  To  show  that  these  charges  are  not  made  M'ithout  some  foundation, 
and  that  some  reason  for  the  demand  that  is  being  pressed  for  a  reform  ih  our  asylum 
statistics  does  exist,  I  will  quote  some  interesting  cures  from  the  general  register  of  this 
asylum. 

"  During  the  two  years  previous  to  May  20th,  1880,  we  find  among  the  '  cures '  the  fol- 
lowing remarkable  cases.  I  quote  from  the  male  register,  and  presume  the  female  regis- 
ter shows  an  equal  proportion  of  remarkable  cures  : 

Cures. 

"  Duration  of  insanity  over  50  years,    ........       i 

"  "  "     20    " 6 

"  "  "     18    " 3 

"      15     " 3 

"                "           "      12     "..,.....       3 
"  "  "       6    " 16 

Total  over  six  years,    .         .         .         .         .         .         .         .         .     32 " 


TREATMENT    OF    INSANITY.  1 69 

Thus  in  the  course  of  two  years,  and  from  the  men's  department  alone,  thirty-two 
cases  were  discharged  as  recovered,  in  no  one  of  wliich  had  the  disease  existed  less  than 
six  years.  In  one  it  had  existed  fifty  years,  and  the  average  duration  for  the  whole  was 
more  than  twelve  years.  "  Four  of  these,"  continues  the  doctor,  "  were  cases  of  chronic 
dementia ;  four  were  epileptic,  with  duration  of  insanity  ranging  from  seven  years  to 
twenty-one  years." 

No  man  who  has  had  any  considerable  experience  in  a  hospital  for  the  insane  can  fail 
to  instantly  perceive  the  preposterous  absurdity  of  such  statistics  as  these.  By  a  proba- 
bly low  estimate  there  are  now  in  the  public  institutions  of  Massachusetts  not  less  than 
fifteen  hundred  insane  pei-sons  who  might  be  set  at  liberty  and  reported  as  "  cured  "  or 
"  recovered  "  with  as  much  propriety  as  were  those  thirty-two  patients  at  the  Athens 
Asylum.  But  by  those  thirty-two  cases — together,  undoubtedly,  with  similar  ones  from 
the  female  department — the  superintendent  increased  the  proportion  of  his  "  cures  "  to 
63.50  per  cent. 

I  am  still  of  the  opinion  that  "  the  medical  officers  of  institutions  for  the  insane  can 
claim  no  exemption  from  the  common  weaknesses  of  human  nature;"  that  "they  are 
men  with  like  passions  as  other  men,"  and  that  the  degree  of  confidence  which  is  to  be 
placed  in  their  statistics  depends,  to  a  large  extent,  upon  the  temperament  and  character 
of  the  individual  from  whom  they  come. 

Other  statistics  are  as  follows,  at  hospitals  for  the  insane  who  base 
their  calculations  on  cases  discharged  : 

Statistics  of  Utica,  N.  ¥.,  Asybim. — -'The  Fortieth  Annual  Report 
of  the  New  York  State  Lunatic  Asylum,  at  Utica,  which,  owing  to 
the  politeness  of  Superintendent  Dr.  John  P.  Gray,  I  have  before  me, 
shows  that  during  the  year  1882  there  were  treated  1038  cases — 
508  men  and  530  women.  The  number  at  the  commencement  of 
the  year  was  626.  Received  from  September  30th,  1881,  to  Sep- 
tember 30th,  1882,  412  cases.  The  daily  average  under  treatment 
was  621.  There  were  discharged,  recovered,  109  cases;  improved, 
46  cases;  unimproved,  235  cases;  not  insane,  13  cases;  died,  57. 
The  thirteen  cases  were  not  insane  when  admitted.  Dr.  Gray  has 
some  excellent  remarks  upon  early  treatment,  which  we  insert  as 
follows  : 

Dr.  Gray  deprecates  the  remarks  of  Dr.  Pliny  Earle,  showing  that 
insanity  is  not  so  curable  as  was  formerly  supposed,  and  says,  "  he 
takes  the  results  growing  out  of  the  public  policy  of  indifference  and 
neglect,  instead  of  basing  his  calculations  upon  what  a  wise  and 
humane  policy  could  effect,"  etc.  Dr.  Gray  thinks  the  apparent 
increase  of  insanity  in  New  York  State  is  due  to  accumulation.  He 
has  also  some  wise  remarks  relative  to  the  premature  removal  of  pa- 
tients from  asylums.  His  remarks  on  the  necessity  of  statutes  making 
provision  permitting  persons  to  be  voluntary  applicants  for  admission 
to  asylums,  are  worthy  of  remark.     We  certainly  need  such  statutes. 


I/O 


PSYCHOLOGICAL  MEDICINE. 


A  man  who  feels  his  brain  out  of  order  is  just  as  much  entitled  to 
be  a  voluntary  applicant  as  a  man  with  a  broken  limb. 
Dr.  Gray  says : 

Importance  of  Early  Treatment. — I  deem  it  proper  to  say  that  a  greater  propor- 
tion than  in  any  previous  year  of  the  cases  admitted  belong  under  the  head  of  chronic 
insanity.  In  my  last  annual  report  statistics  were  presented  showing  the  percentage  of 
patients,  for  each  year,  for  the  ten  previous  years,  who  had  been  insane  a  year  or  more 
before  admission.  I  continue  this  table,  as  it  not  only  shows  how  large  a  proportion 
are  practically  chronic  cases  when  admitted,  and  that  the  evil  practice  of  delay  is  in- 
creasing : 


Year. 

Whole  number 
admitted. 

Found 

not 
Insane. 

Number  Insane 

One  Year  and 

over. 

Percentage  Insane 

One  Year  and 

over. 

1871,       .... 

516 

13 

212 

42.14 

1872, 

399 

17 

143 

37 

43 

1873. 
1874, 

1875, 
1876, 

410 
368 
432 
436 

13 

6 

15 
8 

142 
117 
136 

35 
32 
32 
32 

76 

32 
61 

24 

1877, 

460 

13 

149 

33 

33 

1878, 
1879, 
1880, 

427 
418 
468 

10 
16 
II 

125 

135 

177 

29 

35 
38 

97 
58 
73 

1881, 

411 

8 

190 

47 

14 

1882, 

412 

13 

190 

47 

61 

5.157 

143 

1,854 

36-97 

As  of  further  and  important  interest  in  this  connection  the  following  table  has  been 
prepared,  to  show  how  wide  a  difference  exists  between  the  recoveries  in  recent  cases  and 
n  those  not  placed  under  treatment  until  the  disease  was  fully  established : 


TREATMENT    OF    INSANITY. 


171 


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1/2  PSYCHOLOGICAL   MEDICINE. 

It  -n-ill  be  seen  from  the  above  table  that  the  average  percentage  of  recoveries  on  the 
admissions  for  the  past  ten  years  is  32.55,  while  the  percentage  of  recoveries  of  those 
vi'ho  were  retained  at  home  without  treatment  until  their  insanity  had  continued  a  year  or 
longer  is  only  12.34. 

To  exhibit  more  clearly  the  importance  of  early  treatment,  a  computation  of  the  recove- 
ries of  those  admitted  during  the  same  period  who  had  been  insane  less  than  a  year, 
shows  the  percentage  of  recoveries  increased  over  the  general  average  of  32.55  to  44.06, 
and  the  percentage  of  recoveries  of  those  brought  within  six  months  of  the  attack  rises  to 
46.01. 

It  will  be  observed  that  out  of  the  4129  insane  admitted  during  the  last  ten  years  1499 
were  not  brought  to  the  asylum  until  after  their  insanity  had  lasted  a  year  or  more.  If 
they  had  been  brought  within  a  year  of  the  beginning  of  the  attack,  instead  of  a  per- 
centage of  recovery  of  12.34  it  would  have  been  44.06,  amounting  to  475  more  persons 
cured. 

To  say  nothing  of  the  individual  and  family  sorrow  entailed  by  such  neglect,  the  sub- 
ject possesses  an  economic  aspect  which  demands  consideration.  At  a  low  estimate  the 
individual  expectation  of  life  of  those  475  cases  is  15  years.  Estimating  the  average 
yearly  cost  for  their  support  at  §150,  the  expense  to  the  public  or  their  friends  would  reach 
the  sum  of  ^1,068,750. 

These  figures,  far  more  forcibly  than  words,  show  the  evils  of  delay  in  placing  the 
insane  under  treatment,  and  I  am  forced  to  the  conclusion,  from  experience  and  observa- 
tion, that  the  unjust  crusade  against  asylums  is  largely  responsible  for  this  wrong  inflicted 
on  the  insane,  and  for  the  increase  of  chronic  insajie  with  the  public  and  private  burdens 
it  imposes. 

Bearing  in  mind  what  has  already  been  stated,  that  the  tendency  to  delay  has  recently 
been  growing  instead  of  decreasing,  for  the  tables  show  that  for  the  past  two  years  the 
percentage  of  chronic  cases  admitted  has  risen  from  an  average  of  34.08  to  over  47  per 
cent.,  the  outlook  for  the  insane  and  for  those  upoa  wliom  their  support  will  fall  is  not 
encouraging. 

Dr.  Gray's  remarks  on  restraint  and  seclusion  are  based  on  the 
broad  grounds  of  the  welfare  of  the  patient  and  his  care  and  speedy 
cure,  and  are  given  as  follows,  as  his  wide  experience  entitles  such 
remarks  to  be  attentively  considered.  His  interesting  remarks  on 
the  Commitment,  Detention,  and  Discharge  of  patients  are  also  given 
in  the  few  following  pages,  and  will  repay  careful  reading : 

Restraint  ajid  Seclusion. — Two  years  ago,  I  submitted  to  the  board  of  managers,  in 
compliance  with  their  request,  as  an  appendix  to  my  annual  report,  a  paper  on  the  custody 
and  treatment  of  the  insane,  which  included  a  full  presentation  of  the  status  of  profes- 
sional opinion  at  that  time  on  the  question  of  mechanical  restraint,  with  an  analysis  of 
the  recent  discussions  on  the  subject  held  at  meetings  of  the  medico-psychological  so- 
cieties of  Germany  and  France,  whose  members  are  principally  superintendents  of  insti- 
tutions for  the  insane.  In  these  discussions  both  sides  of  the  question  were  thoroughly 
explored,  and  the  verdict  to  which  the  evidence  led  was  simply  that  restraint  is  not  to  be 
used  for  its  own  sake  or  for  the  mere  convenience  of  officers  and  attendants,  but  as  the 
interests  of  the  patient  alone  required,  to  facilitate  his  proper  treatment  and  recover)'; 
that  the  minimum  of  restraint  consistent  with  the  welfare  of  the  patient  and  the  safety 
of  those  around  him  should  be  aimed  at,  and  that  the  nature  of  the  restraint  required  in 


TREATMENT   OF    INSANITY.  1/3 

each  particulai-  case,  whether  by  camisole,  seclusion,  padded  rooms,  shower  baths  and 
packing,  dry  or  wet,  must  be  determined,  like  the  prescription  of  therapeutic  remedies, 
solely  by  the  judgment  of  the  medical  officers  who  were  responsible  for  all  branches  of 
treatment.  All  the  participants  in  the  discussion  allowed — even  those  who  proclaimed 
themselves  to  be  the  warmest  advocates  of  non-restraint — exceptional  cases  which  cover 
the  whole  ground  of  the  principle  under  discussion,  and  in  fact  narrow  down  the  whole 
debate  to  the  simple  question  whether  seclusion  or  solitary  confinement,  with  hands  and 
limbs  in  free  and  violent  motion  to  do  what  the  patient  may  be  driven  to  do  by  his  dis- 
ease, or  forcible  restraint  by  the  hands  of  attendants,  is  better  than  the  open  association 
and  intercourse  with  other  patients  and  liberty  to  move  about  the  wards,  only  with  hands 
rendered  incapable  of  doing  harm  by  some  mechanical  means.  This  is  a  question  which 
experience  alone  can  determine,  and  I  have  no  hesitation  in  declaring  that  experience  by 
all  means  favors  society  as  against  seclusion  in  such  cases. 

It  was  shown  in  this  same  paper  that  the  so-called  *  abolition  of  restraint '  in  the 
English  asylums  must  not  be  understood  in  an  absolute  sense;  for  whatever  theory  or 
line  of  practice  has  been  adopted,  we  find  there  are  still  cases  which  require  '  strong 
dresses,'  'endless  sleeves,'  'camisoles,'  'tied  hands,"  'forcible  holding  by  attend- 
ants,' '  wet  or  dry  packing,'  or  '  seclusion  in  dark  or  padded  rooms,'  and  the  reasons 
generally  given  for  any  of  these  forms  of  restraint  are  for  '  surgical  purposes,'  or  '  vio- 
lence and  destructiveness,'  or  '  picking  the  face,'  or  '  to  prevent  suicide,'  or  '  self- 
irijui-y  and  mutilation,'  or  '  persistent  destructiveness,'  or  '  self-denuding,'  etc.  I  sum- 
med up  that  paper  with  the  following  conclusions,  which  I  wish  here  to  reiterate,  as  what 
every  passing  year's  experience  has  only  served  to  confirm  and  corroborate. 

"  It  would  seem  that  the  English  superintendents  and  the  commissioners  have  the  same 
exceptional  classes  to  deal  with,  and  that  they  find  in  practice  some  mode  of  protective 
restraint  must  be  resorted  to.  Their  variations  of  practice  would  indicate  that,  instead 
of  a  settled  conviction  of  the  benefit  of  some  particular  method,  they  were  disposed 
rather  by  a  variety  of  means  to  apply  whatever  might  be  the  best  to  accomplish  the  de- 
sired object  of  necessary  protective  control  with  the  least  discomfort  and  risk  to  the  pa- 
tient. We  are  obliged  to  take  it  for  granted  that  those  who  have  figured  as  advocates  of 
non-restraint  do  not  really  mean  the  abandonment  of  all  coercive  measures,  for,  after  all, 
seclusion  against  the  will  of  the  patient,  or  the  use  of  padded  rooms,  wet  and  dry  pack- 
ing, showering  and  manual  force  of  attendants,  can  be  regarded  in  no  other  light  than 
as  restraint. 

"  I  think  it  must  be  admitted  from  the  foregoing  that  there  is  no  real  difference  in  prin- 
ciple among  experienced  professional  men  who  have  devoted  their  lives  to  this  branch  of 
science  applied  to  the  practical  ends  of  humanity  and  benevolence.  Compared  with  the 
manner  in  which  the  insane  were  treated  in  former  times,  the  present  system  is  indeed 
one  of  '  non-restraint.'  Intelligent  medication,  exercise  in  the  fresh  air,  good  and  abun- 
dant food,  moderate  and  pleasant  amusements,  congenial  occupation  as  far  as  practicable, 
combined  with  comfortable  surroundings,  have  proved  a  sufficient  treatment  for  the 
greater  proportion  of  the  insane,  so  far,  at  least,  as  to  make  the  necessity  of  forcible 
means  and  mechanical  appliances  the  '  exception  to  the  rule.'  But  as  these  exceptional 
cases  do  exist,  on  the  universal  confession,  and  always  will,  they  require  exceptional 
treatment.  How  their  best  and  most  humane  care  can  be  accomplished  is  the  serious 
problem  that  brings  itself  to  every  conscientious  mind.  The  principles  on  which  all 
must  agree  are  simply  these :  the  guiding  object  should  be  the  welfare  of  the  patient 
(not  forgetting  also  the  safety  of  those  about  him),  his  care  and  cure  in  the  surest  and 
speediest  manner  possible.  The  responsibility  of  all  measures  to  these  ends  must  rest 
upon  medical  decision  and  judgment  alone ;  whether  control  over  extreme  violence, 


1/4  PSYCHOLOGICAL   MEDICINE. 

manifesting  itself  suicidally  or  homicidally,  shall  be  established  by  the  simplest  mechani- 
cal restraint,  or  by  drugs,  or  by  the  application  of  water  in  shower-baths,  or  by  wet  pack- 
ing, or  by  the  hands  of  attendants,  with  all  the  risks  of  personal  struggles,  or  by  seclusion 
in  rooms  with  or  without  clothing  or  bedding,  with  the  risk  of  self-injury  by  such  means 
as  still  remain  to  the  patient,  or  by  any  other  measures  known  to  science  and  experience, 
must  all  depend  ultimately  upon  what  the  medical  man  on  the  whole  shall  deem  best  for 
the  patient.  All  this  must  come  under  the  one  head  of  medical  care  and  treatment,  pre- 
cisely as  is  the  case  with  the  physicians  in  general  practice  in  the  treatment  of  other  dis- 
eases, or  the  treatment  of  any  disease  in  any  ordinary  hospital,  with  this  difference,  per- 
haps, that  whatever  the  physician  in  the  case  of  the  insane  in  hospitals  advises,  he  is  ex- 
pected to  see  carried  out.  Wherever  the  question  of  restraint  arises  in  connection  with 
any  individual  case  among  his  patients,  he  must  judge  of  the  nature  and  extent  of  that 
restraint,  and  he  must  be  presumed  to  know  and  be  able  to  judge  between  what  is  cruel 
and  what  is  humane,  protective,  and  curative,  as  well  as  the  surgeon  knows  and  judges 
in  his  operations  between  necessary  pain  and  useless  barbarity." 

In  view  of  the  continued  agitation  of  this  subject,  I  have  only  the  following  considera- 
tions to  add  :  Nobody  disputes  that  mechanical  restraint  could  be  wholly  abandoned.  So 
could  the  administration  of  medicine  be  wholly  discontinued.  There  may  be  those  who 
are  prepared  to  take  this  extravagant  ground  in  regard  to  both ;  but  the  real  question,  at 
least  among  experienced  men,  is  whether  restraint  should  he  abandoned;  whether  such 
a  course  would  be  best  for  the  insane.  It  is  upon  this  test  our  practice  must  depend, 
whether  in  itself  the  practice  be  agreeable  or  disagreeable.  I  stated  in  my  annual  report 
more  than  twenty  years  ago  (i860),  before  most  of  the  agitators  of  the  present  day  came 
upon  the  stage,  that  restraint  and  seclusion  were  in  themselves  inadmissible,  and  only  to 
be  used  as  a  necessary  and  indispensable  means  of  treatment.  There  is  abundance  of 
experience  on  record  in  regard  to  this  subject.  The  discussion  of  restraint  on  its  merits 
has  long  since  been  so  exhausted  as  to  render  all  that  can  now  be  said  mere  repetition  and 
altogether  inadequate  as  a  means  of  new  notoriety.  The  conclusions  of  the  Association 
of  American  Superintendents,  of  the  Psychological  Society  of  Paris,  and  the  German  and 
English  authorities  who  represent  experience  with  the  insane,  have  settled  every  princi- 
ple in  this  matter,  and  left  only  the  discretion  of  reducing  the  minimum  to  nothing.  But 
the  fact  is  restraint  has  never  been  wholly  abandoned  either  in  England  or  any  other 
country.  The  most  that  can  be  said  is  that  certain  persons  say  they  do  not  use  it.  Their 
real  practice  is  open  to  the  inquiry  whether  their  substitutes  are  better  for  the  patient 
or  worse.  The  practice  of  not  using  a  remedy  which  all  admit  to  be  only  for  exceptional 
cases  may  conform  to  a  dogma  by  a  physician  more  than  it  contributes  to  the  comfort  or 
recovery  of  a  patient,  which  latter  are  liable  sometimes  to  be  lost  sight  of  in  the  ardor  of 
defending  a  theory.*  I  have  heard  some  say  they  would  not  under  any  circumstances 
prescribe  chloral,  and  others  say  the  same  of  alcoholic  stimulants.  Such  utterances  may 
be  honest.     It  does  not,  however,  follow  that  they  are  wise.     They  do  not  make  their 

*  Note. — Dr.  Tuke,  in  the  "  History  of  the  Insane,"  etc.,  already  referred  to  in  the 
account  of  Broadmoor  Asylum,  says  there  is  no  mechanical  restraint  resorted  to,  but  adds, 
"some  patients  are,  of  course,  secluded  in  a  single  room  in  which  a  bed  made  on  the 
floor  is  the  only  furniture  allowed,  and  in  which  the  window  is  protected  by  a  shutter  if 
the  patient  breaks  glass.  The  room  is,  when  the  shutter  is  closed,  only  partially  dark,  as 
there  are  two  small  windows  near  the  ceiling  out  of  the  patient's  reach.  By  the  side  of 
the  door  is  an  inspection  plate,  or  narrow  slit  in  the  wall,  with  a  movable  glazed  frame, 
opening  outwards,  through  which  the  occupant  of  the  room  can  be  observed  when  nec- 
essary." 


TREATMENT    OF    INSANITY.  1/5 

authors  safe  guides.  Evils  are  said  to  grow  out  of  the  medical  use  of  many  remedies. 
The  use  and  recognition  of  opium  by  medical  science  as  a  valuable  remedy  in  certain 
cases  to  relieve  pain,  to  secure  sleep,  etc.,  gives  it  an  indorsement  which  does  not,  how- 
ever, warrant  its  indiscriminate  use.  Persons  may  use  it,  even  medically,  when  it 
should  not  be  resorted  to,  but  even  this  is  no  argument  against  its  proper  use  in  the  hands 
of  the  experienced  for  the  relief  of  human  suffering.  So  of  any  other  remedies,  such 
as  the  bromides,  very  common  remedies  liable  to  abuse.  Their  safe  administration  is 
looked  for  only  at  the  hands  of  experienced  and  conscientious  men.  The  question  is,  why 
should  not  this  same  principle  govern  the  use  or  non-use  of  mechanical  restraint  in  the 
treatment  of  the  disease,  insanity  ?  We  are  not  advocates  of  restraint  any  more  than 
we  are  advocates  of  cutting  off  limbs.  Neither  is  to  be  resorted  to,  except  as  medical 
treatment. 

Commit7nent,  Detention,  and  Discharge  of  Patients. — When  abroad,  in  1879,  I  gave 
special  attention  to  the  questions  of  commitment,  detention,  and  discharge  of  patients ; 
also  to  the  general  management,  internal  and  otherwise,  of  hospitals  for  the  insane,  privi- 
leges granted,  occupation,  treatment,  etc.  I  had  the  honor  and  good  fortune  to  meet 
some  of  the  Commissioners  in  Lunacy,  and  among  them  the  distinguished  chairman,  the 
Right  Honorable  the  Earl  of  Shaftesbury ;  also  some  of  the  most  prominent  present  and 
Ex-Chancery  Visitors  in  Lunacy,  and  many  of  the  medical  superintendents.  From  these 
gentlemen,  as  well  as  from^  personal  observation,  I  was  able  to  obtain  knowledge  of  the 
law  and  practice  obtaining,  and  of  the  government,  general  and  internal,  of  hospitals  for 
the  insane.  I  was  strongly  impressed  with  the  close  resemblance  of  the  law  and  practice 
to  the  State  of  New  York  in  regard  to  the  admission  and  discharge  of  patients,  the  guaran- 
tees, however,  being  greater  in  New  York  than  in  Great  Britain,  especially  in  respect  of 
medical  certificates  and  official  magisterial  interference.  The  New  York  law  and  prac- 
tice in  respect  of  discharge  are  also  much  simpler  in  regard  to  both  private  and  public 
patients.  In  the  appendix  of  my  report  for  1878  I  presented  the  resemblances  and  dif- 
ferences in  these  and  other  respects  between  the  English  I^unacy  Statutes  and  those  of 
New  York. 

I  beg  to  present  here  the  opinions  on  the  English  and  Scotch  laws,  in  their  practical 
application,  on  the  most  important  matters  which  concern  the  insane,  which  were  given 
before  a  Parliamentary  Commission  of  1877,  under  a  resolution  of  Parliament  ordering 
'  that  a  select  committee  be  appointed  to  inquire  into  the  operation  of  the  lunacy  law, 
so  far  as  regards  the  security  afforded  by  it  against  violations  of  personal  liberty.' 

I  might  have  summarized  the  matter  and  thus  brought  it  into  briefer  space,  but  it 
seemed  best,  as  far  as  possible,  to  give  the  exact  language  used.  I  have  drawn  from  the 
testimony  of  men  of  large  experience  and  great  distinction  in  connection  with  the  care  of 
the  insane  and  managment  of  hospitals,  as  well  as  from  the  testimony  of  officials  exer- 
cising governmental  supervision,  and  it  is  an  interesting  and  significant  fact  that  the 
opinions  expressed  before  that  commission  by  the  distinguished  medical  men  called  before 
it,  were  fully  indorsed  by  Lord  Shaftesbury,  a  man  of  such  vast  experience  and  such 
illustrious  name  in  the  annals  of  philanthropy  in  connection  with  the  care  of  the  insane. 
The  unanimous  opinion  of  the  law  held  by  such  men  on  all  vital  points  covering  the  care 
of  the  insane,  and  indorsed  by  such  an  authority  as  Lord  Shaftesbury,  should  be  conclu- 
sive of  its  wisdom  and  practicability. 

The  English  law  in  regard  to  medical  certificates  is  much  simpler  and  much  less 
guarded  than  that  of  the  State  of  New  York.  Two  medical  certificates  are  required  in 
cases  of  private  patients,  and  but  one  in  the  case  of  paupers,  and  no  medical  certificates 
in  the  case  of  chancery  patients.  All  the  qualification  required  is  that  the  medical  men 
*  shall  be  registered  physicians  or  apothecaries.'     They  are  not  required  to  be  approved 


1/6  PSYCHOLOGICAL    MEDICINE. 

by  any  judicial  or  other  authority.  In  New  York  the  law  requires  in  all  cases,  pri- 
vate or  public,  two  medical  certificates,  and  these  must  be  made  under  oath  by  med- 
ical men,  authorized  as  examiners,  and  the  certificates  must  be  approved  in  writing  by  a 
judge. 

Mr.  Perceval,  Secretary  of  the  Lunacy  Commissioners,  on  his  examination  before  the 
Parliamentary  Committee  of  1877,  testified,  in  answer  to  the  question,  'Is  it  necessary 
that  the  two  medical  men  who  sign  the  certificates  should  be  qualified  practitioners  ? ' 
that  up  to  1S58  there  were  no  qualifications  specified;  that  patients  could  be  sent  by  a 
physician,  apothecary,  or  surgeon;  that  the  medical  act  of  1858  provided  for  the  registra- 
tion of  all  medical  practitioners,  and  when  the  lunacy  acts  were  last  amended,  in  1862, 
advantage  was  taken  of  that  circumstance  to  get  a  proper  definition  of  the  words  'phy- 
sician, apothecary,  or  surgeon.'  These  words  throughout  the  lunacy  acts  now  mean 
medical  practitioners  registered  under  the  Act  of  1858,  and  no  other  person  can  sign  a 
certificate. 

"  Q.  He  may  be  a  physician,  surgeon,  or  apothecary  ? 

"  A.  He  may  be  a  physician,  surgeon,  or  apothecary.  We  do  not  care  what  he  is,  so 
long  as  he  is  a  registered  medical  practitioner.  He  has  such  a  qualification  as  entitles 
him  to  be  on  the  register,  and  that  is  sufficient. 

"  The  English  law  provides  that  the  medical  man  must  have  seen  a  patient  within  seven 
days  before  admission;  copies  of  the  certificates  are  sent  to  the  Commissioners  in  Lu- 
nacy within  twenty- four  hours  after  the  admission  of  the  patient,  and  any  defects  may  be 
remedied  within  fourteen  days  after  being  issued,  and  the  certificates  must  always  be  in 
form.  The  New  York  law  provides  that  the  certificates  must  be  in  form  as  required  by 
the  Commissioners  in  Lunacy,  and  must  be  completed  and  approved  by  the  court  within 
five  days. 

"  Mr.  Perceval  testified  in  regard  to  private  patients  that  two  medical  certificates  and  a 
request,  or  order,  by  some  friend  or  acquaintance,  are  all  that  is  required ;  in  regard  to 
public  patients  an  order  of  the  magistrate  accompanied  by  one  certificate.  To  the  ques- 
tion whether  the  certificates  should  not  be  countersigned  by  some  public  officer,  he 
answered :  '  I  do  not  think  there  would  be  any  additional  protection  to  the  patient  at 
all ;  but  there  are  of  course  two  sides  to  every  question,  and  you  would  interpose  an  addi- 
tional difficulty,  no  doubt,  if  that  is  your  object,  upon  that  which  is  hard  enough  already.' 

"  Q.  I  -wish  to  know  whether  you  do  not  think  there  should  be  some  public  officer,  or 
some  public  record  of  the  incarceration  of  people  against  their  will? 

"  A.  You  have  a  public  record,  and  I  do  not  personally  think  that  the  intervention  of 
a  public  officer  would  be  of  any  material  value  at  all  to  the  liberty  of  the  subject.  It 
would  certainly  not  be  a  material  guaranty,  and  it  would  oppose  an  additional  difficulty 
to  the  earlier  treatment  of  insanity,  which  is  so  very  important. 

"  Q.  Are  there  different  forms  of  insanity,  some  of  which  may  be  aggravated  by  early 
treatment,  and  others  cured  ? 

"  A.  That  is  a  medical  question  which  I  leave,  if  you  will  allow  me,  to  the  medical  wit- 
nesses." 

"  Mr.  "Jaines  Wilkes,  one  of  the  Commissioners  of  Lunacy,  in  answer  to  the  question  : 
'  Do  you  think  the  protections  which  the  law  at  present  provides  against  the  detention 
of  persons  who  are  not  lunatics  are  quite  sufficient  to  protect  the  interests  and  person  of 
the  subject  ? '  replied  :  '  I  think  they  are ;  I  must  say  that  if  I  myself  were  to  be  insane, 
or  had  any  one  belonging  to  me  afflicted  in  that  way,  I  should  place  perfect  reliance  in 
the  present  safeguards  which  the  certificates  and  orders  provide  ? 

"  Q.  Do  you  regard  the  medical  certificate  as  in  itself  a  pei'sonal  protection  to  liberty  ? 

"  A.  Of  course  it  would  not  be,  apart  from  the  order  and  statement,  but  it  is  a  most 


TREATMENT    OF   INSANITY.  1 77 

important  thing  in  deciding  on  the  insanity  or  not  of  a  patient,  and  as  to  the  propriety  of 
placing  that  patient  under  care  and  treatment. 

"  Q.  Do  you  think  the  precautions  which  the  law  at  present  provides  sufficient  ? 

"  A.  Yes,  sir. 

"  Q.  The  certificate  now  is  permanent,  lasting  until  the  patient  is  discharged ;  do  you 
think  that  is  a  good  thing,  or  that  the  certificate  ought  to  be  for  a  limited  time  and  renew- 
able? 

"  A.  I  do  not  think  there  is  any  necessity  for  renewing  it.  Many  of  the  patients  in 
licensed  houses  are  very  poor;  they  are  received  and  kept  really  at  rates  which  are  little 
above  pauper  rates,  and  any  additional  certificate  would  be  a  tax  upon  the  friends,  for  I 
presume  it  would  fall  on  the  friends,  and  I  really  do  not  know  what  good  it  would  do. 

"  Q,  I  understood  you  to  say  that  you  think  it  desirable  in  all  cases  that  they  should  be 
very  early  treated? 

"  A.  I  think  so. 

"  Q.  You  make  no  exception  ? 

"  A.  No,  sir.  There  may  be  an  exception  as  to  the  period  ;  it  depends  upon  what  is 
called  early  treatment.  There  might  be  some  very  slight  insanity,  a  first  attack,  which 
gets  well  very  rapidly,  perhaps  before  any  one  would  think  of  removing  a  patient  to  an 
asylum. 

"  Q.  You  think  there  are  no  cases  of  a  very  excitable  temperament,  in  which,  being 
sent  to  those  places,  might  increase  the  complaint  and  tendency  to  mania  ? 

"A.  No,  sir;  I  do  not  think  so.  I  think  the  removal  from  home  associations  and 
from  the  exciting  causes  of  the  disease,  tends  very  rapidly  to  the  recovery  of  the  patient." 

Dr.  y.  Lockhart  Robertson,  one  of  the  Lord  Chancellor's  visitors  in  lunacy,  and 
previously  a  medical  superintendent,  was  examined.  To  the  question  as  to  qualifications 
of  the  physician,  he  replied :  "  I  do  not  think  a  special  knowledge  of  lunacy  is  so  im- 
portant as  being  a  well-educated  physician. 

"  Q.  Are  you  of  the  opinion  that  the  present  mode,  by  the  certificate  of  two  medical 
men,  surgeons  for  instance,  or  apothecaries,  is  a  sufficient  safeguard  to  the  liberty  of  the 
subject. 

"  A.  I  think  it  is.  I  think  the  difficulty  is  to  get  the  certificates.  I  think  medical 
men  are  so  afraid  of  actions  that  the  great  difficulty  is  to  get  the  certificates  signed.  In  an 
urgent  case  early  treatment  is,  of  course,  of  great  importance  to  the  patient. 

"  Q.  You  are  decidedly  of  the  opinion  that  the  safeguards  against  the  improper  ad- 
mission and  detention  of  persons  in  asylums,  hospitals,  and  licensed  houses  are  practi- 
cally sufficient,  and  that  a  more  complicated  system  of  checks  would  do  more  harm  than 
good  ? 

"  A.  Yes,  decidedly." 

Dr.  Robertson  expressed  the  opinion  that  it  might  be  desirable  to  have  some  official 
order  by  a  magistrate  in  cases  of  private  patients.  This  would  give  protection  to  the 
friends  as  well  as  the  physicians  making  the  certificates. 

Dr.  y.  Crichton-Browne ,  Lord  Chancellor's  visitor  in  lunacy,  and  previously  a  med- 
ical superintendent,  was  examined. 

"  Q.  I  will  ask  you  the  same  question  that  I  asked  Dr.  Robertson.  Are  you  deci- 
dedly of  the  opinion  that  the  safeguards  against  improper  admission  and  detention  of 
persons  in  asylums  are  practically  sufficient,  and  that  a  more  complicated  system  of 
checks  would  do  more  harm  than  good  ? 

"  A.  I  am. 

"  Q.  That  is  an  opinion  based  on  your  experience  in  your  official  capacity,  and  also  on 
your  previous  experience  ? 

12 


178  PSYCHOLOGICAL   MEDICINE. 

"A.  It  is. 

"  Q.  I  do  not  know  whether  you  concur  with  Dr.  Robertson  in  the  opinion  that  the 
additional  order,  or  inquiry,  before  a  magistrate  might  be  desirable  in  the  case  of  private 
patients,  generally  speaking. 

"  A.  Before  a  magistrate  ? 

"  Q.  Yes;  such  a  one  as  is  now  in  use  with  regard  to  pauper  patients? 

"  A.  I  really  do  not  believe  that  there  would  be  any  additional  security  in  such  a  pro- 
vision; in  signing  the  orders  for  pauper  patients  many  magistrates  regard  it,  if  a  certificate 
is  in  due  form,  as  a  ministerial  act.  They  sign  the  order  merely  as  a  matter  of  course. 
Such  an  arrangement  with  reference  to  private  patients  might  cause  delay,  as  it  does  some- 
times in  the  case  of  paupers,  when  there  is  a  difficulty  in  finding  a  magistrate.  I  think, 
also,  it  might  increase  the  prejudice  against  asylum  treatment.  The  public  would  look  upon 
insanity  as  in  some  way  connected  with  crime,  if  a  patient  had  to  be  taken  before  a  mag- 
istrate. 

"  Q.   Would  you  recommend  that  the  certificates  should  be  renewed  from  time  to  time  ? 

"A.  I  have  thought  over  that,  and  I  do  not  think  that  would  be  any  additional  safe- 
gxiard. 

"  Q.  Might  not  some  system  of  medical  referees  in  such  a  case  possibly  be  established 
instead  of  taking  any  chance  medical  man  that  comes  first  ?  Might  there  not  be  some 
persons  who  would  pass  an  examination  in  mental  diseases  to  whom  all  these  cases  might 
be  referred  instead  of  taking  the  first  chance  medical  man  ? 

«'  A.  It  might  be  so,  but  I  think  it  would  tend  rather  to  diminish  public  confidence  to 
have  specialists  signing  certificates.  The  public  would  come  to  associate  them  with  mad 
doctors,  and  my  impression  is  that  it  is  better  to  have  general  practitioners  sign  the  cer- 
tificate.    The  public  have  more  confidence  in  the  decision  of  the  ordinarj'  family  doctor." 

Dr^  Browne's  testimony  was  that  early  treatment  was  of  the  greatest  possible  value. 

Dr.  John  Charles  Bucknill,  over  eighteen  years  a  medical  superintendent,  and  Lord 
Chancellor's  visitor  in  lunacy  thirteen  and  one-half  years,  testified  : 

"  Q.  With  reference  to  the  admission  of  private  patients  into  asylums  and  their  dis- 
charge, what  do  you  think  the  principle  of  that  ought  to  be  ? 

"A.  I  think  the  principle  should  be  to  make  the  admission  as  easy  as  possible  in  order 
to  provide  for  early  treatment,  and  to  make  the  discharge  as  easy  as  possible  in  order  also 
to  provide  for  early  treatment,  for  if  there  is  difficulty  in  getting  a  patient  out  of  asylums 
there  will  be  a  disinclination  to  send  them  in.  That  is  a  point  which  has  been  very  well 
worked  out  by  the  Scotch  Commissioners  in  Lunacy,  and  they  have  proved  it  by  statistics." 

Dr.  Bucknill  expressed  the  opinion  that  with  the  medical  certificates  in  case  of  private 
patients  the  law  should  provide  that  the  person  who  gave  the  order  should  bear  some 
relation  to  the  patients,  sapng :  "  As  to  the  person  himself,  the  statute  gives  no  indication 
as  to  who  the  person  should  be,  and,  in  point  of  fact  and  practice,  the  most  improper 
persons  may  sign  the  order.  A  gentleman's  footman  may  sign  for  the  gentleman's  son ; 
a  foreigner  will  sign  for  his  lunatic  friend  and  leave  the  countiy  immediately;  a  solicitor's 
clerk  will  sign  ;  all  manner  of  people  will  sign — people  who  cannot  be  held  responsible. 

"  Q.  You  think  the  order  is  considered  more  as  a  matter  of  form,  and  that  the  certifi- 
cate of  the  medical  man  is  really  relied  upon  ? 

"A.  Xo  ;  the  real  power  is  possessed  by  the  man  who  signs  the  order.  The  certificate 
and  the  order  go  together.  With  regard  to  the  admission  :  the  patient  once  admitted,  the 
man  who  signs  the  order  holds  the  staff  to  such  an  extent  that  the  patient  cannot  be 
removed  from  the  asylum  unless  the  person  who  signed  the  order  is  incapable.  If  he 
becomes  incapable  by  disease  or  by  insanity,  or  if  he  is  dead  or  has  left  the  country,  then 
the  statute  lays  down  the  rule  that  certain  other  persons  may  order  the  discharge;  but 


TREATMENT    OF    INSANITY.  1 79 

otherwise,  if  he  is  not  incapable,  no  one  but  the  person  who  has  signed  the  order  can  pro- 
cure the  discharge  of  a  patient  once  admitted  into  a  licensed  house  or  a  hospital. 
"  Q.  What  remedy  would  you  propose  for  such  a  state  of  things  as  that  ? 
"  A.  It  is  very  difficult  to  meddle  with  the  existing  forms  without  increasing  the  difficulty 
of  obtaining  early  treatment;  I  think  that  the  rule  which  has  been  laid  down  with  regard 
to  the  discharge  of  patients  from  asylums,  namely,  that  if  a  man  who  signs  the  order  is 
incapable,  then  the  husband  or  wife  could  act,  and  if  there  be  no  husband  or  wife,  then 
the  father  or  mother,  or  the  next  of  kin  may  very  well  be  introduced  in  the  order  for 
admission;  that  if  a  patient  has  a  husband  or  wife  he  or  she  should  sign  the  order,  or,  in 
default,  the  father  or  mother,  or  next  of  kin,  or  a  solicitor  could  for  any  of  these  or  in 
case  of  a  lunatic  who  has  no  relative  to  be  found,  I  think  a  solicitor  might  be  employed 
to  act  for  any  friend. 

"  Q.  You  have  travelled  a  good  deal  in  America  and  examined  the  state  of  things 
there ;  can  you  tell  us  what  the  American  law  is  in  regard  to  the  admission  and  deten- 
tion of  persons  in  asylums  ? 

"A.  It  varies  in  every  State.  A  good  deal  of  change  has  taken  place  quite  recently; 
the  State  of  New  York  seems  to  have  made  the  best  change.  There  the  certificates  before 
the  year  before  last  could  be  signed  by  any  two  men  calling  themselves  medical  men. 
The  new  law  requires  that  they  shall  be  qualified  medical  men  and  that  they  shall  also 
have  a  certificate  from  some  judge  of  a  court  of  record,  to  whom  they  are  personally  known 
as  competent  for  their  duties.  An  attempt  is  being  made  to  create  a  class  of  medical  men 
who  understand  something  about  insanity  and  are  capable  of  giving  certificates. 

"  Q.  Have  you  considered  whether  easy  discharge  from  asylums  would  tend  to  the  more 
frequent  admissions  to  the  asylums  in  the  early  stages  of  the  disorder  and  to  the  early 
treatment  of  the  disease  ? 

"  A.  vSir  James  Coxe  has  clearly  pointed  out  that  not  only  the  highest  percentage  of 
cases  but  the  shortest  duration  of  treatment  in  Scotland  is  found  in  the  Renfrewshire  asy- 
lums, which  are  parochial  asylums,  in  which  the  inspectors  of  the  poor  can  put  a  patient 
on  the  outbreak  of  insanity  without  any  difficulty,  and  also  remove  him  without  any  diffi- 
culty whatever.  He  points  out  that  the  authorities  of  asylums  might,  perhaps,  unwillingly 
increase  the  indisposition  to  place  patients  in  asylums  by  throwing  impediments  in  the 
way  of  their  easy  removal  from  asylums.  I  take  it  that  the  succession  of  events  which 
Sir  James  points  out  is  this, — that  you  get  easy  discharge  from  these  Renfrewshire  paro- 
chial asylums ;  therefore  you  get  early  treatment  and  a  much  larger  percentage  of  cures 
effected  in  short  time. 

"  Q.  You  think  that  in  all  cases  it  is  a  great  object  to  get  early  treatment  ? 
"  A.  Yes ;  I  think  that  is  the  greatest  point  to  aim  at. 

"  Q.  Therefore,  if  the  facility  of  obtaining  the  discharge  would  induce  the  people  to 
send  all  patients  in  the  early  stages  to  the  asylums,  the  percentage  of  cures  would  be 
greater  and  the  cures  would  be  more  rapid  ? 
"A.  Yes;  that  is  exactly  what  I  mean." 

Sir  yames  Coxe,  of  the  Board  of  Lunacy  in  Scotland,  testified  : 

"  Q.  In  the  report  of  the  General  Board  of  Commissioners  of  Lunacy  for  Scotland,  for 
the  year  1859,  signed  by  yourself,  there  are  one  or  two  paragraphs  which  I  should  like  to 
read  to  you  :  '  It  cannot  be  too  often  repeated  that,  in  the  treatment  of  insanity,  loss  of 
time  is  unfavorable  to  recovery,  or  that  every  impediment  that  is  thrown  in  the  way  of 
immediate  treatment  acts  most  prejudicially  upon  the  patient  by  tending  to  render  perma- 
nent the  aberration  from  normal  action  which,  under  favorable  circumstances,  would 
speedily  have  subsided.'  Is  that  your  opinion  ? 
"  A.  Yes,  sir. 


l80  PSYCHOLOGICAL   MEDICINE. 

"  Q.  '  We  are  therefore  of  opinion  that  asylums  are  capable  of  rendering  to  mankind 
far  greater  services  than  they  have  yet  achieved  ;'  is  that  also  your  opinion  now  ? 

"  A.  Yes,  sir.  Sir  James  Coxe  testified  that  the  medical  certificates  were  acted  upon  in 
Scotland  by  the  sheriff.*  '  In  the  case  of  the  sheriff  there  is  no  reference  to  any  inde- 
pendent medical  man  at  present.' 

"  Q.  The  sheriff  himself  determines  for  himself  whether  the  grounds  stated  by  the 
medical  men  are  sufficient  ? 

"A.  Yes. 

"  Q.  He  does  not  refer  it  to  any  independent  medical  man  ? 

"A.  No;  he  judges  for  himself. 

"  Q.  In  your  judgment,  would  it  be  an  improvement  that  the  certificates,  before  being 
acted  upon,  should  be,  if  necessarj',  canvassed,  and  further  inquiry  directed  by  some 
independent  medical  official  ? 

"  A.  I  think  it  would  merely  complicate  matters. 

"  Q.  You  think,  in  practice,  it  is  a  sufficient  precaution,  the  sheriff  examining  the  cer- 
tificates and  the  grounds  stated  in  them  ? 

"  A.  I  think  so." 

Dr.  Ha7-7-ington  Tukt,  Fellow  of  the  Royal  College  of  Physicians  of  London,  having 
had  practice  at  Han\vell,  under  Dr.  Conolly,  and  at  present  having  charge  of  a  private 
asylum  at  Chiswick,  testified  : 

"  Q.  Would  you  suggest  that  no  certificates  should  be  signed  except  by  medical  men 
who  had  special  practice  in  lunacy  ? 

"A.  I  would  rather  suggest  that  the  knowledge  of  lunacy  should  be  made  more  gen- 
eral than  it  is. 

"  Q.  You  would  not  have  a  special  class  of  medical  men  for  lunacy  cases  ? 

"  A.  No ;  I  think  not. 

"  Q.  We  have  had  the  opinion  already  expressed  both  ways,  that  there  should  be  a 
special  class  of  medical  men,  skilled  in  lunacy,  who  should  sign  one  of  these  certificates, 
and  also  that  it  would  be  a  mischievous  thing  to  have  any  special  class  of  that  sort  ? 

"  A.  I  think  there  would  be  less  confidence  of  the  public  in  specialists  in  any  particular 
class  than  any  two  physicians  taken  at  hazard,  but  I  think  that  the  physicians  should  be 
better  trained. 

"  Q.  Are  you  of  opinion  that  it  would  be  desirable,  also,  that  the  medical  certificate 
should  have  a  temporary  effect,  or  that  the  certificate  should  be  signed  by  medical  men 
who  had  special  knowledge  of  lunacy  ? 

"  A.  No,  I  am  not  so ;  the  result  of  giving  it  to  special  medical  men  would  lead  to 
still  greater  distrust  than  there  is  at  present,  because,  as  far  as  I  have  seen,  the  ignorance 
of  medical  men  leads  them  to  refuse  to  sign  medical  certificates. 

"  Q.  Would  you  not  think  it  desirable  to  limit  the  effect  of  the  certificate  ? 

"  A.  No,  it  would  lead  to  so  much  mischief  in  so  many  cases  that  I  doubt  its  efhcacy. 
It  would  do  so  much  mischief  to  the  patient  by  the  necessity  of  a  fresh  examination,  and 
then  there  are  actually  so  few  cases  where  there  is  any  doubt,  that  it  would  be  a  great 
pity  to  make  a  general  rule  for  them. 

"  Q.  Do  you  consider  that  if  any  obstacles  were  placed  in  the  way  of  the  committal  of  the 
insane  to  public  or  private  asj^lums  that  would  have  a  tendency  to  interfere  with  the  cure 
and  with  that  early  treatment  which,  we  have  some  evidence,  is  thought  to  be  necessary 
for  cure  ? 

*  Note. — The  sheriff  in  Scotland  approves  certificates  instead  of  the  judges,  as  in  the 

State  of  New  York.     His  office  is  still  that  of  a  local  judge,  and  not  merely  ministerial, 
as  in  England. 


TREATMENT   OF   INSANITY.  l8l 

"  A.  Any  delay  in  instant  medical  treatment  is  most  disastrous.  Dr.  Conolly  and  my- 
self went  over  the  statistics  of  three  asylums  with  which  we  were  connected.  We  found 
that  seventy-seven  per  cent,  that  were  treated  under  three  months  recovered;  those  that 
were  treated  later  diminished  in  an  absolutely  geometrical  ratio,  until  at  last  it  sank  to, 
after  twelve  months,  something  like  twenty  per  cent,  fully  cured.  I  think  any  obstacle 
in  the  way  of  medical  treatment,  either  in  an  asylum  or  otherwise,  most  injurious. 

Dr.  Henry  Maudsley,  a  physician,  practicing  in  London,  testified  that,  in  his  opinion, 
the  law,  "  with  regard  to  the  admission  of  patients  is  sufficiently  stringent  and  quite  as 
stringent  as  can  be  properly  consistent  with  the  treatment  of  insanity  in  its  early  stages." 
He  testified  that  if  insanity  was  to  be  cured,  the  person  must  be  put  under  treatment 
early,  "  because  recoveries  are  entirely  in  proportion  to  the  early  stage  at  which  treat- 
ment is  adopted.  If  regulations  are  made  more  stringent  than  they  are  now  (and,  in- 
deed, the  present  regulation  operates  to  some  extent  in  that  direction),  the  friends  of 
patients  will,  instead  of  sending  them  from  home,  as  is  almost  essential  in  the  case  of  in- 
sanity— unlike,  in  this  respect,  other  diseases — keep  them  at  home  under  improper  con- 
ditions, and  so  very  much  injure  the  chance  of  recovery." 

As  to  any  alteration  in  the  law  touching  the  certificates  he  testified  :  "  I  have  considered 
the  matter.  If  it  is  considered  desirable,  as  I  have  heard  suggested,  that  the  certificates 
should  go  before  some  public  official  before  they  were  acted  upon,  it  seems  to  me  that  no 
public  official  would  be  in  a  better  qualified  posttion,  to  judge  of  the  value  of  the  cer- 
tificates, than  the  commissioners,  to  whom  exact  copies  are  sent  within  twenty-four  hours ; 
indeed,  not  really  so  much  so.  If  he  entered  really  into  the  matter  in  each  case,  it  would 
be  a  very  anxious  responsibility  and  a  formidable  matter  for  him  to  undertake ;  and,  if 
he  did  not,  would  simply  become  a  mere  matter  of  routine,  adding  to  the  publicity,  add- 
ing to  the  expense,  and  adding  to  the  delay  of  getting  a  patient  under  care,  and  would 
make  the  early  treatment  more  difficult  than  it  is." 

Again,  he  testified  that  people  "  would  shrink  very  much  indeed,  according  to  my  ex- 
perience, from  having  a  public  officer  come  in  to  proclaim,  say  a  young  lady  of  eighteen, 
a  lunatic,  or  a  wife  after  childbirth  who  is  insane,  perhaps,  for  a  month  or  two.  To  a 
professional  man  such  a  public  thing  might  be  almost  ruin." 

"  Q.  Would  there  be  greater  publicity  in  that  way  than  there  would  be  from  a  certifi- 
cate given  by  a  medical  man  in  the  neighborhood  ? 

"A.  Yes,  it  would  be  thought  so;  because,  as  a  matter  of  fact,  certificates  are  often 
given  in  this  way :  The  medical  man  of  the  family,  who  is  in  regular  atlendance,  gives 
one  of  the  certificates.  He  calls  in  a  physician  in  consultation,  who  then  sees  the  case 
separately  afterward  and  gives  the  second  certificate.  There  is  no  alarm  of  the  patient. 
It  is  simply  an  ordinaiy  matter  of  consultation  as  it  appears  to  him." 

Dr.  Duckworth  Williatns,  medical  superintendent  of  Sussex  County  Asylum,  Hay- 
ward's  Heath,  testified  : 

"  Q.  Do  you  attach  importance  to  the  pauper  lunatics  being  sent  early  to  the  asylum  ? 

"  A.  Very  great. 

"  Q.  From  the  lunatic  wards  of  the  workhouse  ? 

"  A.  They  should  be  sent  at  once,  in  my  opinion,  without  going  to  the  lunatic  wards 
at  all. 

"  Q.  You  think  that  as  soon  as  the  ordinary  forms  are  complied  with  the  paitient  should 
go  at  once  to  the  asylum  and  not  go  to  the  workhouse  first  ? 

"A.  Certainly. 

"  Q.  Do  you  say  that  because  you  think  there  is  more  chance  of  cure  in  such  cases  ? 

"  A.  Because  there  is  more  chance  of  cure,  and  also  on  the  score  of  economy." 

Dr.  Williams  testified  to  the  evil  of  the  insane  being  taken  to  the  workhouses  without  any 


1 82  PSYCHOLOGICAL   MEDICINE. 

certificate,  which  was  the  common  custom,  and  in  condemning  this,  he  spoke  the  opin- 
ion of  all  the  authorities. 

The  Right  Honorable  the  Earl  of  Shaftesbury,  attended  before  the  committee  by  per- 
mission of  the  House  of  Lords,  and  was  examined.  He  testified  that  he  had  been  a 
member  of  the  lunacy  commission  "  now  close  upon  fifty  years.  I  was  associated  with 
Lord  Gordon  on  the  first  committee  of  inquiry  in  1828,  then  in  1829  in  bringing  in  the 
first  bill  received ;  since  that  time  for  twenty  years  I  was  in  the  habit  of  visiting  con- 
tinually." He  was  permanent  chairman  from  1845.  He  testified  to  the  law  generally, 
and  to  changes  from  time  to  time  in  the  statutes. 

"  Q.  Do  you  consider  that  the  facility  with  which  patients  are  admitted  into  asylums 
is  not  too  great  at  the  present  time  ? 

"  A.  No,  certainly  not.  I  think  that  the  whole  of  our  experience  confirms  us  in  the 
opinion  that  it  is  not.  We  stated  so  in  1859  and  we  state  it  still  more  emphatically  now. 
I  cannot  recollect  a  single  instance  in  which  a  patient  has  been  brought  into  any  asylum 
in  whose  case  there  were  not  sufficient  grounds  for  saying  that  he  was  a  proper  subject 
for  cure  and  treatment ;  I  can  hardly  recollect  a  single  instance.  I  see,  by  referring  to  the 
evidence  which  has  already  been  given  before  your  honorable  committee,  that  such  is  the 
testimony  of  every  man  of  experience  who  has  been  consulted  on  the  matter.  It  was 
likewise  the  opinion  of  the  committee  that  sat  in  1859,  for  they  reported  in  that  sense. 

"  Q.  At  the  same  time  there  is  a  feeling  which  has  been  expressed,  not  only  generally, 
but  by  witnesses  before  the  committee,  that  a  large  number  of  persons  are  admitted  to  the 
asylums  in  a  state  of  sanity  and  kept  there  ? 

"A.  I  have  no  doubt  those  statements  would  be  made,  because  I  never  knew  the  case 
of  a  patient,  either  under  confinement  or  after  confinement,  who  did  not  say  that  he  had 
been  most  unjustly  confined.  I  hardly  know  an  instance.  I  do  not  know  that  any  in- 
stances have  been  adduced  to  prove  the  truth  of  that  allegation. 

"  Q.  At  any  rate,  it  is  your  Lordship's  opinion  that  the  admission  of  patients  into  an 
asylum  is  now  sufficiently  guarded  ? 

"  A.  I  think  so. 

"  Q.  Would  you  say  the  same  with  regard  to  their  detention  there?  Is  it  not  the  case 
that  they  are  sometimes  kept  there  longer  than  is  necessary  ? 

"A.  I  do  not  think  they  are  so  now;  it  was  rather  my  opinion  in  1859  that,  under 
some  circumstances,  they  may  have  been  detained  beyond  the  time  that  it  was  absolutely 
necessary,  but  then  I  think  that  a  great  deal  was  to  be  said  in  extenuation  of  that.  It  is 
a  great  responsibility  to  send  out  a  patient  upon  the  world,  both  with  respect  to  the  pa- 
tient himself  and  in  respect  to  society,  before  you  are  satisfied  that  he  is  cured  or,  at  any 
rate,  in  such  a  state  that  he  can  be  safely  trusted.  Since  1859,  I  should  very  much  modify 
the  opinion  I  then  gave. 

"  Q.  Does  your  Lordship  consider  that  many  of  the  stories  that  we  hear,  from  time  to 
time,  of  conspiracies  and  of  ill-treatment  are  themselves  delusions  in  the  minds  of  people 
who  are  intending  to  say  what  is  accurate  ? 

"  A.  I  think  so  ;  and  it  is  a  very  remarkable  thing  that  in  many  instances  one  of  the 
first  indications  that  a  man  gives,  or  a  woman  gives,  of  a  state  of  aberration,  is  the  belief 
of  a  conspiracy.  I  have  never  heard  of  a  conspiracy  being  formed  for  a  purpose  of  that 
description." 

In  regard  to  chronic  cases  and  others  being  taken  first  to  the  workhouse,  his  Lordship 
testified: 

"I  think  it  highly  necessary  that  in  every  instance  the  patient  should  go  to  the  asylum 
first,  and  pass  from  the  asylum  to  the  workhouse,  and  not  from  the  workhouse  to  the  asy- 
lum, %^'hich  is  very  often  the  case.     He  gets  into  the  workhouse  and  there  is  detained, 


TREATMENT   OF    INSANITY.  "  1 83 

when  if  he  went  to  the  asylum  it  would  be  adjudged  at  once  whether  he  was  a  fit  case  for 
the  asylum ;  and  if  not,  he  would  be  sent  back  to  the  workhouse.  In  that  way  a  great 
number  of  the  recent  cases  are  kept  back  to  a  very  late  period,  when  they  might  have 
been  treated  and  sent  back  to  the  world  perfectly  well. 

"  Q.  The  practice  is  exactly  the  reverse  of  what  it  ought  to  be  ? 

«'A.  Yes." 

He  testified  concerning  suicidal  and  homicidal  cases  to  show  the  absolute  necessity  of 
taking  those  cases  in  due  time. 

After  dealing  with  the  statistics  of  suicide  at  large,  he  stated  that  there  were  then  in 
confinement  in  the  various  asylums,  six  thousand  and  ninety-six  suicidal  patients.  Refer- 
ring to  the  criminal  asylum  at  Broadmoor,  he  s^iid  that,  leaving  out  all  that  were  there 
for  minor  causes,  "  there  were  one  hundred  and  forty-five  men  charged  with  murder.  In 
seventy-five  cases  the  insanity  was  not  recognized  before  the  commission  of  the  crime. 
In  twenty-nine,  insanity  was  recognized,  but  the  persons  were  reputed  harmless.  In 
thirty-three,  the  insanity  was  recognized  in  the  persons,  not  probably  recognized  as  being 
altogether  harmless,  but  insufiicient  precautions  were  taken.  In  eight,  exact  circum- 
stances were  not  known." 

Of  ninety-eight  "  charged  with  attempts  at  murder,  maiming,  or  stabbing,  in  forty-two 
the  disease  was  not  recognized  before  the  commission  of  the  crime;  in  twenty-nine  they 
were  reputed  harmless ;  of  twelve  insufficient  care  was  taken ;  and  in  fifteen  the  exact 
circumstances  were  not  known.  When  you  come  to  the  women,  there  are  seventy-one 
women  charged  with  murder;  in  twenty-eight  the  insanity  was  not  recognized  before 
the  commission  of  the  crime ;  in  thirteen  the  insanity  was  recognized,  but  the  persons 
were  reputed  harmless ;  in  twenty-three  the  insanity  was  recognized  and  the  persons 
were  not  regarded  as  altogether  harmless,  but  insufficient  precautions  were  taken.  Then 
you  come  to  the  stabbing;  in  four  the  insanity  was  not  recognized;  in  six  they  were 
reputed  harmless;  in  two  sufficient  precaution  was  not  taken."  He  adds:  "This  is  a 
very  important  matter,  because  it  shows  the  very  large  number  of  cases  in  which,  through 
inattention,  the  insanity  is  not  detected  till  an  overt  act  has  been  committed.  That  is 
the  evil  way  in  which  a  large  proportion  of  the  public  judge  of  sanity  or  insanity.  They 
will  never  hold  a  person  to  be  insane  until  some  overt  act  has  been  committed,  and  that 
is  always,  invariably,  the  case  before  juries.  Then  an  overt  act  having  been  committed 
furnishes  a  proof  that  the  disorder  is  very  far  advanced,  almost  to  be  inveterate,  and 
consequently  incurable.  What  I  state  shows  the  absolute  necessity  of  great  precautions, 
the  absolute  necessity  of  paying  attention  to  the  earliest  stage  of  the  disorder,  and  though 
I  could  by  no  means  render  admission  into  the  asylums  more  easy  than  it  is,  I  most  un- 
doubtedly would  not  render  it  more  difficult,  because  I  am  certain  society  is  in  very 
great  danger.  We  always  have  felt,  as  commissioners,  that  we  have  a  double  duty.  We 
have  a  duty  to  the  patient  and  a  duty  to  society.  We  have  a  duty  to  the  patient  to  see 
that  he  is  not  needlessly  and  improperly  shut  up ;  but  we  have  also  a  duty  to  society  to 
see  that  persons  who  ought  to  be  under  care  and  treatment  should  be  under  care  and 
treatment,  and,  moreover,  that  they  should  not  be  set  at  large  before  they  can  be  consid- 
ered safe  to  mix  in  society. 

"  Q.  Do  not  these  facts,  which  are  very  remarkable,  point  rather  to  a  want  of  knowl- 
edge of  lunacy  among  medical  men  ? 

"  A.  No ;  I  think  not.  I  am  not  going  to  say  that  there  is  sufficient  knowledge  of 
lunacy  among  medical  men,  but  such  cases  as  this  have  never  been  brought  under  their 
observation;  they  have  been  suffered  to  roam  about;  nobody  has  taken  any  trouble 
about  them ;  in  the  case  of  many  of  them  the  family  did  not  suspect  the  madness ;  they 
might  have  thought  the  man  was  queer,  and  they  never  thought  of  consulting  a  doctor 


184  PSYCHOLOGICAL  MEDICINE. 

on  the  matter.  I  have  no  doubt  a  great  number  of  medical  men,  if  they  had  seen  such  a 
case  at  an  early  period,  would  have  come  to  the  right  conclusion  about  it.  As  I  was 
saying,  the  large  mass  of  society,  even  educated  persons,  are  wholly  unable  to  form  an 
opinion  unless  they  see  something  that  is  very  decided  ;  that  they  consider  an  aben-ation  ; 
something  very  peculiar  ;  something  out  of  the  common  way  ;  another  is  this, — it  very 
often  happens  a  great  change  of  character  is  very  often  the  indication  of  coming  insanity, 
and  then  many  people  say,  and  very  naturally,  '  What  is  the  matter  with  this  person  ?  he 
is  getting  very  cross ;  he  is  quite  a  changed  man ;  he  is  not  half  as  good-humored  as  he 
used  to  be  ;  he  has  become  crabbed  and  ill-tempered ;'  they  do  not  see  that  this  very 
often  is  an  indication  of  his  approaching  insanity ;  they  put  it  down  to  a  sudden  change 
of  temper. 

"  Q.  Has  your  lordship  any  suggestions  to  make  upon  that  point  ? 

"  A.  No  ;  I  have  no  suggestions  to  make,  because  I  am  very  unwilling  to  say  anything 
that  should  restrict  in  any  way,  more  than  is  now  restricted,  the  person  or  liberty  of  the 
subject;  I  only  wish  to  call  greater  attention  to  these  things,  that  people  may  have  their 
eyes  open,  and  then  they  may  put  their  heads  together  and  see  if  they  can  devise  some- 
thing by  which  a  remedy  may  be  applied,  but  I  have  no  particular  suggestion  of  my  own 
to  make  ;  I  only  give  it  as  a  very  striking  fact,  and  one  that  should  put  us  on  our  guard 
very  much  against  juries,  because  they  never  deal  with  the  matter  unless  there  is  an  overt 
act,  which  overt  act,  ninety-nine  cases  out  of  one  hundred,  is  a  proof  that  the  disorder  is 
incurable." 

In  regard  to  medical  certificates  his  lordship  testified : 

"  It  is  very  remarkable,  taking  it  altogether,  that  the  certificates  have  been  so  sound, 
considering  the  great  number  that  have  been  given  every  year.  Of  course,  we  must  admit 
that  they  have  been  signed  by  medical  men  who  have  no  very  extensive  knowledge  of 
lunacy,  but  it  is  certainly  very  remarkable  that  the  number  of  certificates  which  have 
passed  through  our  hands  since  1859 — the  date  of  the  last  committee — amounts  to  more 
than  185,000,  and  yet  of  all  those  certificates  I  do  not  think  so  many  as  half  a  dozen  have 
been  found  defective.  It  sounds  very  well  to  say  that  persons  acquainted  with  lunacy 
should  be  the  only  persons  to  sign  certificates,  but  the  fact  is,  as  matters  now  stand,  that 
a  great  amount  of  scientific  knowledge  as  to  lunacy  is  not  possessed  by  many  people  ; 
there  are  a  certain  number  who  are  well-informed,  but  the  great  mass  of  the  community 
know  very  little  about  it,  and  with  the  large  number  of  the  insane — dispersed,  as  they 
are,  all  over  the  country — you  must  trust  to  the  medical  men  of  the  several  districts.  I 
have  a  very  strong  opinion  on  this  point.  The  certificates  hitherto  have  been  very  cor- 
rect, and  I  am  quite  certain  that,  out  of  the  185,000,  there  was  not  one  who  was  not 
shut  up  upon  good,  fair,  prima  facie  e'v'idence  that  he  ought  to  be  under  care  and 
treatment;  such  is  the  testimony  of  all  the  physicians  of  note  who  have  been  sum- 
moned before  this  committee;  for  what  does  that  arise  from — it  does  not  arise  from 
the  great  knowledge  of  the  medical  men  of  the  lunacy  that  they  handle,  but  it  arises 
in  a  great  measure  from  the  habit  of  keeping  back  the  patients  so  long,  because  the 
parents  and  friends  do  not  like  to  admit  to  themselves  that  the  patient  is  affected, 
and  so  delay  to  call  in  a  medical  man.  And  then  begins,  when  the  medical  man  is 
at  last  called  in,  the  fear  and  apprehension  that  the  patient  may  be  sent  to  a  lunatic 
asylum  and  the  whole  affair  become  public;  so  that  when  the  final  examination  is 
made  by  the  medical  man,  who  has  to  sign  the  certificate  to  send  them  to  an  asylum,  the 
symptoms  are  so  evident  and  so  pronounced  that  few  people  can  mistake  them.  I  have 
very  little  doubt  that  such  is  the  case  and  such  is  the  reason  why  we  have  so  few  faulty 
certificates.  But,  on  the  other  hand,  what  follows  from  that  course  ?  Why,  that  the 
cases  are  very  far  advanced,  and  have  got  pretty  nearly  in  the  category  of  the  incurable. 


TREATMENT   OF    INSANITY.  1 85 

"  Q.  And  this  is  not  very  satisfactory  ? 

"  A.  Very  far  from  it." 

His  lordship  testified  against  special  doctors  making  certificates  : 

"I  think  something  has  been  said  about  having  what  they  call  a  system  of  special 
doctors.  I  confess  to  you  that  I  have  a  very  great  fear  of  a  special  doctor.  But,  assum- 
ing them  to  be  good,  in  the  first  place  they  must  be  very  numerously  spread  over  Eng- 
land and  Wales,  because  they  are  wanted  at  the  instant,  and  were  there  not  an  ample 
supply  of  them  you  have  to  send  a  great  distance  to  reach  these  special  doctors.  I 
should  like  to  see  how  Parliament  would  define  a  special  doctor  before  I  can  give  an 
opinion.  I  confess  I  should  be  very  much  alarmed  if  there  were  persons  who  kept  them- 
selves exclusively  to  that  study  without  a  constant  experience  of  both,  of  all  the  various 
circumstances  that  beset  lunacy  at  large  and  under  confinement,  moral  as  well  as  physi- 
cal, that  attend  it;  all  the  social  circumstances,  the  ten  thousand  other  circumstances. 
....  I  remember  the  case  very  well  of  a  medical  man,  a  doctor,  an  excellent  man,  who 
thought  that  I  had  some  influence  in  obtaining  the  appointment  of  medical  men  to  the 
commission.  I  knew  him  very  well.  He  came  to  me  and  told  me  what  he  wished.  To 
show  his  extraordinary  knowledge  of  the  subject  he  gave  me  a  sheet  of  paper  as  big 
as  that,  with  a  list  of  the  forms  of  insanity.  'My  dear  sir,'  said  I,  'this  will  never 
do.  If  you  reduce  your  principles  to  practice  you  will  shut  up  nine-tenths  of  the  people 
in  England  ;'  and  so  they  would.  If  you  have  special  doctors  they  would  shut  up  people 
by  the  score. 

"  Q.  There  was  another  proposal,  which  was  to  require  a  certain  knowledge  of  lunacy 
on  the  part  of  the  medical  officers  of  health,  and  who  are  scattered  over  the  country,  and 
to  employ  them  as  checks  upon  the  asylums  and  as  a  kind  of  deputy  visitors,  to  supple- 
ment the  visits  of  the  commission  ? 

"  A.  To  that  I  should  very  much  object.  I  wish  to  speak  with  the  greatest  respect  of 
them,  but  I  think  medical  officers  of  health,  to  a  great  extent,  are  young  men  and  unin- 
structed  men  who  have  taken  the  office  merely  because  they  think  it  gives  them  a  posi- 
tion and  qualifies  them  to  get  on  in  their  profession.  They  are  not  likely  to  have  any 
great  knowledge  of  lunacy.  Then,  again,  being  local  people,  they  would  be  in  friend- 
ship or  in  antipathy  with  the  superintendents  of  asylums.  Consider  another  point :  we 
must  do  everything  we  can  to  keep  the  best  medical  men  in  the  service  and  to  get 
them  to  sign  the  certificates.  I  am  sorry  to  say  that  now  the  very  best  medical  men 
refuse  to  have  anything  whatever  to  do  with  the  certificates,  they  are  so  afraid  of  the 
responsibility  and  of  being  '  hauled  over  the  coals,'  as  the  phrase  is,  that  they  will  not 
do  it. 

"  Q.  Another  proposal  was  to  take  a  person  whose  mind  was  affected  to  a  hospital 
where  he  would  be  treated  as  he  would  be  in  any  other  hospital,  and  that  afterward, 
provided  he  became  fully  insane,  he  should  go  to  an  asylum,  but  that  otherwise  he 
might  be  restored  to  society  without  having  any  taint  of  insanity  upon  him  ? 

"  A.  I  think  it  would  eventually  come  to  the  same  thing.  These  probationary  asy- 
lums would  be  considered  lunatic  asylums,  and  it  would  be  said  of  the  people  taken 
there :  '  Oh,  you  know  he  escaped  going  to  the  asylum,  that  is  true,  but  he  was  in  a 
probationary  asylum.  He  was  so  queer  and  so  odd  that  they  were  obliged  to  send 
him  there.'  The  taint  of  lunacy,  which  I  see  this  committee  is  so  justly  afraid  of, 
would  be  as  much  fastened  on  him  as  if  he  had  gone  direct. 

"  Q.  In  process  of  time  the  hospital  would  get  the  character  of  a  lunatic  asylum. 

"  A.  Yes,  they  would  be  called  semi-lunatic  asylums  and  all  that  sort  of  thing.  They 
would  come  under  the  same  category  at  last." 

In  regard  to  certificates  his  Lordship  further  testified : 


1 86  PSYCHOLOGICAL   MEDICINE. 

"  Q.  Should  you  not  think  it  an  additional  security  to  the  freedom  of  the  subject  if 
one  of  the  signers  of  the  certificates  was  a  person  in  some  official  capacity  ?  Now,  as 
your  Lordship  is  aware,  there  are  two  medical  men — they  may  be  surgeons,  apothecaries, 
or  physicians — who  sign  the  certificates.  Do  not  you  think  it  would  be  an  improvement 
if  one  of  the  signers  of  the  certificates  was  in  some  public  capacity  ? 

"  A.  No,  sir.  In  the  first  place  I  should  be  sorry  not  to  have  two  medical  certificates 
for  the  confinement  of  any  patient  in  a  licensed  house.  I  do  not  know  where  we  could 
find  a  public  man  who  was  also  a  medical  man. 

"  Q.  By  a  public  capacitj'  I  meant  an  officer  connected  with  the  union,  or  somebody 
responsible  to  the  public. 

"  A.  I  think  it  was  the  right  honorable  chairman  who  put  the  question  to  me  the  other 
day  on  that  subject.  I  said  I  strongly  objected  to  an  officer  of  the  union.  He  was  not 
a  man  of  sufficient  standing.  Oftentimes  he  has  merely  taken  his  place  because  it  gives 
him  a  status.  He  is  not  a  man  of  sufficient  standing.  Some  of  the  medical  men  who 
sign  the  certificates  are  of  verj'  high  standing  and  degree,  and  you  could  not  allow  them 
to  be  overruled  by  an  inferior  officer. 

"  Q.  Do  you  not  think  that  it  would  be  an  improvement  if  the  certificates  did  not  par- 
take of  the  final  character  they  now  assume  ;  that  they  should  be  of  a  more  temporary 
character  than  they  are  now  ? 

"  A.  I  do  not  think  so. 

"  Q.  We  \^-ere  told  that  in  Scotland  the  patients  cannot  be  sent  to  the  lunatic  wards  of 
workhouses  without  a  certificate.     Does  your  Lordship  consider  this  a  good  plan  ? 

"  A.  An  excellent  plan ;  it  is  not  the  same  with  us. 

"Q.  In  England,  of  course,  a  lunatic  may  be  sent  to  the  lunatic  ward  of  a  workhouse 
without  any  certificate  at  all  ? 

"  A.   Yes;  the  relieving  officer  may  send  him  in,  or  any  one  may  send  him  in. 

"  Q.  He  only  wants  a  certificate  signed  when  he  goes  into  an  asylum  from  the  lunatic 
ward  ? 

"A.  Quite  so. 

"  Q.  You  think  the  Scotch  plan  of  requiring  the  certificate  upon  the  lunatic  going  in 
the  lunatic  ward  of  the  workhouse  is  preferable  ? 

"  A.  Very  much  preferable. 

"  Q.  We  have  had  evidence  from  the  Scotch  Commissioners  in  Lunacy,  in  which  com- 
parisons very  favorable  to  the  Scotch  system  have  been  drawn,  with  regard  to  the  interven- 
tion of  the  sheriff.  Your  Lordship  has,  I  think,  already  expressed  an  opinion  with  regard 
to  the  inter\'ention  of  a  public  authority.  Would  you  consider  that  the  prospects  of  cure 
derived  from  placing  a  patient  under  early  treatment  would  be  considerably  interfered 
with  if  the  law  were  altered  so  as  to  necessitate  the  intervention  of  the  magistrate  in  this 
country  ? 

"  A.  Most  undoubtedly ;  the  great  fear  in  England  of  so  many  people  is  publicity,  and 
anything  that  tends  to  bring  the  patient  before  the  public  and  to  make  the  case  of  a  pa- 
tient notorious,  would  induce  people  to  keep  that  patient  so  long  as  they  could  before 
they  submitted  him  to  the  treatment  of  an  asylum  or  of  a  single  house.  It  would  inter- 
fere very  materially  with  it.* 

"  Q.  On  the  whole,  your  opinion  is  most  decided  that  the  intervention  of  the  magistrate 

*  In  the  present  movement  toward  lunacy  reform  in  our  own  country,  all  sides  of  the 
question  should  be  attentively  weighed  and  considered,  and  especially  the  above  point  of 
the  possibility  of  doing  the  patient  himself  great  harm  by  measures  intended  for  his  wel- 
fare bv  reformers. 


TREATMENT   OF    INSANITY.  '  1 8/ 

would  be  injurious  to  the  person,  as  regards  his  recovery,  and  no  protection  to  him  as 
regards  his  liberty  ? 

"  A.  None  whatever.  I  think  it  would  take  away  nine-tenths  of  the  protection  he 
now  has.  I  cannot  conceive  anything  which  to  my  mind  would  be  worse.  I  will  do  any- 
thing that  I  can  in  the  world  to  protect  the  patient,  but  I  know  if  I  were  to  assent  to  what 
is  proposed  I  would  assent  to  that  which  would  be  irreparable  injury. 

"  Q.  I  think  your  Lordship  is  under  some  misapprehension  as  to  the  part  that  the  sheriff 
acts  in  the  matter:  he  has  the  option  of  acting  according  to  his  own  discretion,  either 
ministerially  or  judicially.  He  may  judge,  and  usually  does,  of  the  fitness  of  the  evidence 
upon  which  the  medical  men  grant  the  certificate,  or  he  may  not  do  so.  He  may  judge, 
and  usually  does,  of  the  fitness  of  the  persons  to  give  evidence  under  the  circumstances; 
for  instance,  relationship,  or  anything  of  that  kind,  might  be  regarded  as  a  disqualifying 
characteristic  in  a  person  signing  a  certificate  ? 

"  A.  That  is  what  we  should  object  to ;  we  should  object  to  any  inexperienced  layman 
taking  upon  himself  to  reverse  the  decision  of  the  medical  man. 

"  Q.  He  would  not,  in  that  case,  reverse  their  decision.  He  would  merely  remit  it  to 
other  medical  men,  who,  in  his  opinion,  were  competent  to  grant  the  certificate. 

"  A.  It  is  all  very  right  that  it  should  be  so,  but  then  see  what  it  ends  in.  It  ends, 
after  all,  in  the  opinion  of  a  medical  man,  for  it  is  only  one  set  of  medical  men  against 
another  set." 

Hospital  Ward  for  Sick  Men. — In  my  report  for  1854  I  stated:  "Our  arrangements 
for  taking  care  of  the  sick,  though  probably  as  good  as  those  of  any  other  similar  insti- 
tution, must  be  regarded  as  very  imperfect.  All  sick  patients  should  be  immediately 
removed  from  the  wards  to  a  hospital  department  properly  arranged,  where  every  atten- 
tion demanded  by  their  condition  could  be  bestowed ;  where  the  physician  could  visit 
them  frequently  during  the  day  and  in  the  night,  if  necessary,  without  disturbing  others ; 
where  those  very  ill  could  be  visited,  and,  if  advisable,  nursed  by  their  friends,  and  the 
dying  be  administered  to  without  exciting  the  fears  of  others." 

I  have  in  several  reports  since  recommended  the  erection  of  a  hospital  for  the  sick. 
In  the  second  annual  report  of  the  State  Board  of  Charities,  in  referring  to  the  asylum, 
they  say :  "  There  should  be  erected  two  small  wards,  one  for  each  sex,  for  the  treatment 
of  the  sick  and  feeble,  that  their  friends  may  be  able  to  visit  them  and  remain  near  them 
without  disturbing  a  large  number  in  a  general  ward.  This  improvement  is  demanded, 
not  only  by  humanity,  but  decency,  especially  in  the  case  of  female  patients,  who  are 
frequently  admitted  to  the  asylum  in  a  condition  which  justifies  and  demands  seclusion 
and  the  most  tender  care." 

In  my  report  for  1872  this  matter  was  again  urged  upon  the  legislature  and  the  atten- 
tion of  the  governor  and  comptroller  was  called  to  this  point  when  they  visited  the  insti- 
tution, and  they  approved  the  application.  Finally,  in  1875,  an  appropriation  was  made 
for  a  special  hospital  building  for  sick  women.  These  arrangements  have  proved  most 
satisfactory.  There  should  be  hospital  wards  for  sick  men  also.  This  is  a  great  defect 
which  should  be  remedied.  The  facts  and  reasons  heretofore  given  in  support  of  the 
measure  have  increased  weight,  with  the  enlargement  of  the  institution.  I  sincerely 
hope  the  legislature  will  make  the  necessary  appropriation.  A  small  two-story  build- 
ing, placed  a  little  back  of  the  front  wing  and  connected  by  a  corridor,  for  this  purpose, 
would  not  cost  over  $15,000,  and  would  make  provision  for  fifteen  patients  and  the 
necessary  attendants,  bath-rooms,  etc. 

Atmisetiients. — Amusements  are  conceded  to  be  a  very  necessary  feature  in  connection 
with  the  modern  hospital  for  the  insane,  and  undoubtedly  a  very  important  means  of 
comfort,  enjoyment,  and  recovery.     Few  of  the  institutions  in  America  are  adequately 


1 88  PSYCHOLOGICAL   MEDICINE. 

equipped  in  tliis  respect.  Amusements  are  universally  considered  an  important  auxiliary 
in  the  treatment  of  insanity.  In  the  early  history  of  the  institution  theatrical  and  other 
entertainmehts  -were  held  upon  the  wards  by  the  erection  of  a  temporary'  stage,  taken  down 
from  time  to  time.  These,  however,  were  limited  quarters,  and  there  was  but  room  for  a 
veiy  small  proportion  of  the  patients  to  attend. 

Later  a  small  theatre  room  was  arranged  in  the  attic  of  the  central  building,  which, 
though  a  very  great  improvement  on  the  former  accommodations,  has  two  very  serious 
drawbacks.  First,  the  limited  capacity  of  the  room,  it  not  being  large  enough  to  accom- 
modate more  than  one-third  of  the  patients  at  a  time ;  second,  its  loeation  in  the  attic 
of  a  building  four  stories  high.  The  amusement  halls  of  American  institutions  are  in  sad 
contrast  with  those  in  Great  Britain.  Dr.  Bucknill,  in  his  visit  to  this  country  in  1875, 
was  present  at  one  of  our  entertainments,  and  very  justly  says  in  his  remarks  upon  this  insti- 
tution :  "  I  assisted,  by  my  presence,  at  some  capital  amateur  theatricals  in  which  the 
amateurs  were  patients  and  attendants,  and  the  audience  of  lunatics  were  neither  dull 
nor  disorderly.  The  recreation  room,  however,  is  not  worthy  of  the  asylum,  and  the 
governors  would  do  well  to  provide  a  better  one."  In  connection  with  this  institution 
and  the  class  of  patients  we  receive,  a  recreation  hall  should  be  built  large  enough  to  ac- 
commodate the  whole  household,  and  should  be  built  upon  the  ground  floor,  that  all  the 
old  or  feeble  persons  and  all  patients  who  could  reasonably  control  themselves  could  be 
present  at  entertainments.  Such  a  building  could  be  erected  without  great  cost  in  the 
rear  court-yard  which  persons  could  reach  from  all  parts  of  the  building,  and  where  there 
would  be  no  uneasiness  or  anxiety  in  regard  to  escape  in  case  of  any  accident.  A  plain 
structure  in  accordance  with  the  surrounding  rear  buildings  could  be  put  up  at  an  expense 
of  not  to  exceed  $10,000. 

Statistics  of  Bloojningdale,  N.  Y.,  Asyliwi. — The  annual  report  of 
the  Bloomingdale  Asylum  for  the  Insane,  New  York  city,  for  which 
we  are  indebted  to  Dr.  Charles  H.  Nichols,  the  medical  superinten- 
dent, shows  that  during  the  year  1882  there  were  treated  in  this  in- 
stitution 330  patients, — 157  men  and  173  women.  The  number  of 
patients  under  treatment  on  the  ist  of  January,  1882,  was  224;  ad- 
mitted during  the  year,  106.  The  discharges  were :  recovered,  39; 
improved,  34;  unimproved,  ii  ;  died,  23  ;  remaining  at  end  of  year, 
223  patients.  Ninety-two  of  the  admissions,  or  87  per  cent,  of  the 
whole  number  admitted,  were  first  attacks.  Respecting  restraint. 
Dr.  Nichols  says  :  "  I  am  in  full  accord  with  what  may  be  properly 
called  the  American  doctrine  and  practice  in  the  use  of  mechanical 
restraint  and  seclusion  in  the  treatment  of  the  insane,  which  is,  as  I 
understand  it,  that  neither  mode  of  treatment  shall  ever  be  resorted 
to,  unless,  in  the  opinion  of  a  competent  and  responsible  medical 
officer,  protection,  in  particular  cases,  against  violence,  exhaustive 
activity,  the  removal  of  surgical  dressings,  etc.,  etc.,  can  be  effected 
more  easily,  completely,  and  beneficially  to  the  patient  than  the  nec- 
essary end  can  be  attained  by  either  the  hands  of  attendants,  medici- 
nal agents,  shower  and  douches,  which  I  consider  inadmissible,  ex- 


TREATMENT   OF    INSANITY.  "  1 89 

cept  in  a  very  limited  number  of  cases,  or  '  pack,'  wet  or  dry,  which 
are  obviously  a  very  positive  form  of  mechanical  restraint,  although 
their  therapeutical  advantages  may  now  and  then  be  superior  to  any 
substitute  for  them,  and  that  it  is  the  duty  of  the  practitioner  to  re- 
sort to  mechanical  restraint  or  seclusion  whenever  he  clearly  sees 
that  it  is  needed,  upon  the  grounds  stated.  Of  course,  the  actual 
practice  in  the  use  of  restraint  varies  more  or  less  in  different  institu- 
tions like  this,  as  I  believe  it  does,  actually  and  necessarily,  in  every 
other  enlightened  country,  and  is  governed,  as  are  other  measures  of 
treatment,  by  the  training  and  character  of  the  medical  officers  in 
charge,  the  opinion  and  support  of  trustees,  the  number  and  charac- 
ter of  patients  with  respect  to  the  extent  and  quality  of  their  accom- 
modations, proportion  of  attendants  to  patients,  scale  of  expenditure, 
and  other  agencies  of  treatment.  The  restraint  heeded  in  the  same 
institution  will  vary  greatly,  according  to  the  varying  condition  of 
patients.  While  I  still  conscientiously  entertain  the  views  just  ex- 
pressed, in  common  with  the  great  majority  of  my  American  breth- 
ren, and  am  entirely  unwilling  to  be  governed  by  a  prohibitory  dogma 
or  an  arbitrary  proportion  to  patients  in  the  use  of  restraints,  I  am  of 
the  opinion  that  the  circumstances  that  justify  its  average  use  in 
more  than  2  or  3  per  cent,  of  the  cases  under  treatment  must  be 
quite  exceptional." 

The  Twenty-third  Annual  Report  of  the  State  Asylum  for  Insane 
Criminals,  at  Auburn,  N.  Y.,  for  which  we  are  indebted  to  the  cour- 
tesy of  Dr.  C.  F.  MacDonald,  the  superintendent,  shows  by  its  statis- 
tics that,  from  the  opening  of  this  asylum  in  February,  1859,  ^P  ^^ 
October  l,  1882,  the  total  number  admitted  was  629 ;  the  total  num- 
ber discharged,  488  ;  the  total  number  discharged  recovered,  166; 
the  total  number  discharged  improved,  Gy ;  the  total  number  dis- 
charged unimproved,  116;  the  total  number  discharged  not  insane, 
57.     Speaking  of  the  criminal  insane.  Dr.  MacDonald  says: 

T/ie  Criminal  Insane. — A  great  deal  has  been  said  in  recent  times  respecting  the  psy- 
chology of  crime  and  its  relations  to  mental  disease.  Theories  have  been  advanced  by 
various  writers  to  show  that  tendencies  to  crime  and  criminal  propensities  are  frequently 
inherited  conditions.  Extremists  on  the  one  hand  have  told  us  that  all  criminals  are  vic- 
tims of  mental  disease,  or  infirmity,  and  consequently  not  responsible  for  their  acts ;  while 
on  the  other  hand,  certain  writers  have  proposed  that  lunatics  should  be  held  accountable 
for  acts  of  violence,  and  some  have  even  gone  so  far  as  to  suggest  that  dangerous  insane 
men  should  be  disposed  of  in  the  same  manner  as  are  hydrophobic  dogs. 

From  a  somewhat  extensive  observation  of  several  years,  respectively,  of  the  criminal 
and  non-criminal  insane,  I  am  led  to  believe  that  the  element  of  crime,  when  interwoven 
with  insanity,  exerts  a  modifying  influence  upon  the  mental  manifestations  of  that  dis- 


190  PSYCHOLOGICAL    MEDICINE. 

ease,  and  that  to  this  extent,  in  a  large  proportion  of  cases,  the  criminal  insane,  medically 
speaking,  may  be  regarded  as  a  distinct  and  separate  class,  the  analogue  of  which  is  not 
found  among  the  ordinary  insane.  They  present  certain  characteristic  mental  peculi- 
arities which  experience  in  observing  this  class  enables  one  to  recognize  as  the  indelible 
stamp  of  crime,  and  although  the  line  of  demarcation  may  not  always  be  apparent  to  the 
casual  observer,  its  existence,  as  a  rule,  can  be  discovered  and  demonstrated,  if  time  and 
facilities  for  careful  observation  be  had. 

In  my  experience  with  the  criminal  insane,  now  nearly  five  years,  I  have  been  struck 
with  the  frequency  of  cases  in  which  there  was  an  absence  of  expressed  delusions,  al- 
though the  manner  and  conduct  of  the  individual  was  clearly  indicative  of  a  delusional 
state.  Comparing  these  individuals  with  their  former  selves,  we  find  undoubted  evi- 
dences of  a  departure  from  their  normal  mental  state.  They  have  become  sullen,  mo- 
rose, and  morbidly  irritable.  They  rebel  against  the  ordinary  rules  of  discipline,  and 
make  unprovoked  assaults  upon  those  around  them,  without  apparent  motive  and  without 
offering  any  explanation  therefor.  That  they  are  suffering  from  impairment  of  bodily 
functions  is  shown  by  sleeplessness,  loss  of  appetite,  coated  tongue,  foul  breath,  consti- 
pation, a  "greasy"  condition  of  the  skin,  and  a  livid,  puffy  appearance  of  the  extremi- 
ties, indicating  a  relaxed  state  of  the  bloodvessels.  They  are  generally  coherent  in  con- 
versation, do  not  complain  of  being  ill,  nor  apply  for  medical  treatment.  They  frequently 
continue  in  the  performance  of  their  allotted  tasks  in  prison  for  months  before  the  atten- 
tion of  those  in  daily  contact  with  them  is  attracted  to  their  mental  disturbance.  From 
this  condition  they  either  recover  or  gradually  drift  downward  to  complete  dementia, 
with  no  outward  exhibition  of  delirium  or  mental  excitement,  to  max'k  the  course  of  their 
disease.  The  occurrence  of  acute,  delirious  mania,  according  to  my  observation,  is  ex- 
ceptional among  the  criminal  insane,  melancholia,  and  dementia,  with  an  occasional  case 
of  subacute  mania,  being  the  predominant  types  of  insanity  observed  here.  A  certain 
proportion  of  cases"  and  usually  those  of  hardened  criminals,  are  characterized,  in  their 
mental  manifestations,  by  the  most  pronounced  vicious  tendencies,  their  insanity  appar- 
ently expressing  itself  in  a  marked  exaggeration  of  the  depravity  and  vice  displayed 
by  them  prior  to  the  onset  of  their  disease.  On  the  mental  side,  this  is  substantially  the 
only  evidence  of  disease  which  these  cases  present.  Physically,  however,  their  condition 
is  marked  more  or  less  by  the  signs  of  bodily  impairment  above  referred  to.  Being 
known  to  the  authorities  as  abandoned  and  depraved  individuals,  it  is  not  surprising  that 
their  insanity  is  not  recognized  by  casual  observers,  when  it  expresses  itself  in  the  man- 
ner I  have  indicated. 

We  may  readily  admit  such  cases  into  the  category  of  mental  disease,  without  in  any 
way  countenancing  the  dogma  that  insanity  and  crime  are  convertible  terms.  The  con- 
duct of  such  cases,  when  first  admitted  to  the  asylum,  is  characterized  by  the  most  strik- 
ing evidences  of  depravity.  They  are  profane  and  obscene  in  language ;  tear  and  destroy 
clothing,  bedding,  and  furniture ;  strike,  steal,  lie,  and  soil  themselves  and  their  surround- 
ings, apparently  from  mere  wantonness.  They  sleep  badly,  and  display  the  resistance  to 
the  effects  of  sleep-producing  remedies  common  to  lunatics.  They  are,  generally,  alike 
indifferent  to  coercive  measures  and  to  comfort,  and  it  is  only  by  constant  and  persistent  en- 
deavor, firmly  but  kindly  applied  by  those  in  immediate  charge  of  them,  that  they  can  be 
trained  into  decent  habits  and  deportment.  From  the  foregoing  it  might  naturally  be  infer- 
red that  the  successful  management  of  the  criminal  insane  would  involve  greater  difficulties 
than  are  encountered  in  the  care  of  the  ordinary  insane.  And  such  was  my  belief  in  the 
early  period  of  my  experience  with  this  class,  but  further  observation  and  experience 
have  served  to  convince  me  that,  with  facilities  specially  adapted  to  its  needs,  an  asylum 
for  the  criminal  insane  can  be  conducted  on  the  same  general  principles,  and  with  as 


1 


TREATMENT    OF    INSANITY.  '  I9I 

good  results,  except  in  the  matter  of  cures,  as  are  hospitals  for  the  ordinary  insane. 
Visitors  passing  through  the  wards  of  this  asylum  are  struck  by  the  marked  absence  of 
noise  or  disturbance  of  any  kind,  this  being  the  usual  condition  night  and  day.  They 
not  unfrequently  ask  to  be  shown  "  the  violent  cases,"  and  "  those  you  have  to  keep  tied 
up  in  their  cells,"  or  in  "strait-jackets;"  and  when  informed  that  no  mechanical  re- 
straint of  any  kind  is  used  here;  that  we  have  no  cells;  that  there  is  no  "disturbed" 
ward,  and  that  the  patients  they  have  seen  are  the  worst  cases  we  have,  they  are  apt  to 
look  incredulous  and  doubting,  apparently  being  unable  to  realize  that  criminal  lunatics 
are  controlled  by  kindly  influences,  and  that  order  and  quietude  prevail  among  what  they 
had  supposed  to  be  the  most  violent  class  of  insane.  The  principal  difficulties  encoun- 
tered in  the  management  of  this  institution  are,  the  prevention  of  escapes,  and  a  pro- 
pensity of  certain  hiomicidal  patients  to  obtain  and  conceal  articles  for  the  purpose  of 
using  them  as  weapons  of  assault.  To  prevent  these  occurrences  involves  the  exercise  of 
constant  care  and  vigilance.  Cases  of  simulated  insanity  are  obviously  of  much  more 
frequent  occurrence  here  than  in  general  asylums.  They,  of  course,  are  troublesome 
while  they  remain  with  us,  but  detection  is  not  difficult,  and  is  immediately  followed  by 
a  return  to  prison.  If  it  were  the  rule,  and  generally  so  understood  in  the  prisons,  that 
a  convict  detected  in  an  attempt  to  feign  insanity,  would  forfeit  the  commutation  of  sen- 
tence allowed  him  for  good  conduct,  it  would,  I  believe,  render  such  attempts  of  rare 
occurrence. 

Insane  criminals,  particularly  of  the  convict  class,  in  their  efforts  to  escape,  frequently 
display  a  wonderful  combination  of  shrewdness,  cunning,  and  ingenuity.  Patients  of 
both  classes,  who  have  committed  crimes  against  the  person,  are  more  dangerous,  but  less 
inclined  to  escape  than  are  those  who  have  committed  crimes  against  property. 

Owing  to  the  low  walls  inclosing  the  grounds  about  the  institution  and  the  absence  of 
guards  upon  them,  together  with  the  other  difficulties  referred  to,  it  is  obvious  that  the 
privileges  allowed  patients  here  have  to  be  more  restricted  than  would  be  necessary  in 
other  institutions  for  the  insane. 

In  connection  with  this  subject,  and  illustrating,  in  a  general  way,  some  of  the  princi- 
ples I  have  endeavored  to  carry  out  here,  the  following  extract  from  the  third  annual 
report  of  the  State  Board  of  Health,  Lunacy,  and  Charity  of  Massachusetts,  respecting  a 
recent  visit  of  observation  made  to  the  asylum  by  a  committee  of  that  board,  may  be  of 
interest : 

"  The  only  criminal  asylum  similar  to  those  in  Great  Britain  which  has  been  in  opera- 
tion for  any  considerable  time  in  the  United  States,  is  that  maintained  by  the  State  of 
New  York  in  connection  with  the  State  prison  at  Auburn.*  The  Auburn  Asylum  was 
visited  during  the  summer  by  the  Inspector  of  Charities,  and  again,  on  the  9th  of  Novem- 
ber, 1881,  at  the  special  request  of  the  board,  by  Dr.  Hitchcock,  Dr.  Walter  Channing 
(who  had  been  for  more  than  two  years  a  medical  officer  of  this  asylum  at  a  former 
period),  and  by  the  Inspector  of  Charities.  From  the  notes  made  at  these  visits,  and 
from  the  published  reports  of  this  asylum,  the  following  statements  of  fact  and  opinion  are 
drawn : 

"  The  State  Asylum  for  Insane  Criminals  was  opened  in  connection  with  the  Auburn 
State  Prison*  on  the  2d  of  February,  1859,  and  has  had  an  average  number  of  patients, 
during  the  twenty-two  years  following,  of  something  less  than  loo,  although  of  late  years 
(since  1874)  the  number  of  patients  has  averaged  more  than  100,  and,  in   1880,  rose  to 

*  This  is  an  error.  The  asylum  bears  the  same  relation  to  Auburn  prison  that  it  does 
to  the  other  prisons  of  the  State.  It  has  a  separate  organization  and  is  separated  from  the 
prison  by  a  high  wall. —  C.  F.  M. 


192  PSYCHOLOGICAL   MEDICINE. 

142.  At  the  last  visit  of  the  Inspector  of  Charities  it  contained  135  p^ients,  10  of  whom 
were  women,  the  average  number  having  fallen  a  little  during  1881.  The  whole  num- 
ber of  patients  admitted  since  February  2d,  1859,  does  not  much  exceed  600,  and  of  those 
less  than  40  have  been  women.  Upon  inquiring  of  Dr.  MacDonald,  the  present  super- 
intendent, why  the  State  of  New  York,  with  a  population  of  more  than  5,000,000,  should 
have  so  small  a  population  in  its  only  criminal  asylum,  he  stated  that  the  period  of  deten- 
tion for  his  patients  was  too  short,  and  that  there  were,  in  the  State  of  New  York,  several 
hundred  of  the  criminal  insane,  practically  of  the  same  class  as  those  at  present  under  his 
charge,  who,  in  his  opinion,  ought  to  be  in  such  an  asylum,  provided  it  were  large  enough 
to  contain  them.  He  even  thought  the  number  of  such  patients,  if  the  laws  were  so 
modified  as  to  allow  their  detention  in  his  asylum,  might,  in  a  few  years,  reach  500. 
But  among  those,  he  supposed  that  the  proportion  of  women  might  be  no  greater  than  it 
had  been  among  the  actual  patients  of  the  asylum ;  that  is,  less  than  one  m  fifteen. 

"  Previous  to  the  first  appointment  of  Dr.  MacDonald  as  Superintendent,  in  April, 
1876,  the  management  of  the  asylum  seems  to  have  been  complicated  with  the  manage- 
ment of  the  prison — both  being  guided  too  much  by  political  consideration.  Dr.  Mac- 
Donald's  appointment  was  non-political,  and  under  his  administration  much  has  been 
done  to  improve  the  treatment  of  the  patients  and  the  character  of  the  attendants  who 
take  charge  of  them.  At  the  present  time  the  patients  in  the  Auburn  Asylum,  although 
to  a  large  extent  belonging  to  the  woi'st  class,  both  of  criminals  and  of  the  insane,  appear 
to  be  treated  with  as  little  harshness  and  with  as  much  success  in  regard  to  recovery,  rate 
of  mortality,  etc.,  as  is  found  in  the  ordinary  insane  asylum,  where  chronic  patients 
largely  predominate. 

"  '  We  found  one  or  two  patients  secluded  and  one  undergoing  mechanical  restraint,' 
is  the  statement  made  by  the  gentlemen  who  visited  the  asylum  on  the  9th  of  November. 
A  considerable  number  of  the  patients  labor  regularly  outside  of  the  wards,  and  a  sepa- 
rate ward  has  lately  been  constructed  for  the  residence  of  these  daily  workers.  The 
average  cost  of  each  patient  in  the  asylum,  which  has  ranged,  during  twenty-two  years, 
between  $150  a  year  and  ^600,  now  stands  at  about  ^200,  or  a  little  less  than  $4.  a  week, 
yet  the  food,  clothing,  and  general  care  of  the  patients  seem  to  be  as  good  as  in  the  ordi- 
nary asylum. 

"  The  three  gentlemen  who  visited  the  Auburn  Asylum  in  November  say  : 

" '  As  the  general  discipline  and  surroundings  of  the  patients  there  have  improved,  the 
amount  of  restraint  has  decreased.  In  former  years  harsh  treatment,  amounting  even  to 
the  severity  of  prison  discipline,  was  practiced,  and  restraint  by  handcuffs  and  other 
means  rose  to  ten  per  cent.  The  average  has  steadily  fallen,  year  by  year,  since  Dr. 
MacDonald  took  charge,  in  1876,  and  one  may  almost  predict  that  its  entire  discontinu- 
ance will  soon  be  the  rule.*  For  sixteen  months,  we  were  informed,  there  had  been  no 
escapes,  in  spite  of  the  remarkable  propensity  of  insane  criminals  to  make  attempts. 
Vigilance  is  partly  the  explanation  of  this  long  period  of  immunity,  but  it  is  also,  and 
perhaps  chiefly,  due  to  the  feeling  of  confidence  and  goodwill  engendered  in  the  pa- 
tients by  the  spirit  of  kindness  and  trust  pervading  the  asylum.  Under  the  former 
prison  plan  of  treatment  every  evil  impulse  was  kept  alive,  and  such  patients  as  were 
able  exhausted  the  whole  strength  of  their  minds  in  planning  escapes. 

"  •  We  observed  a  considerable  number  of  patients  out  at  work,  most  of  them 
assisting  the  gardener.  Two  or  three  were  laying  a  pavement,  one  was  carpentering, 
one  was  assisting  the  baker,  and  several  others  were  at  work  in  the  laundry,  in  the 
engine-house,  and  kitchen.     These  men  were  steady  and  regular  workers,  as  a   rule, 

*  No  form  of  mechanical  restraint  has  been  used  since  March,  1882. — C.  F.  M. 


TREATMENT    OF    INSANITY,  1 93 

and  perhaps  even  better  workers  than  the  average  of  insane  men.  In  the  sewing-room 
■we  found  a  discharged  criminally  insane  woman  employed  as  seamstress,  and  we  were 
told  that  a  criminally  insane  man  had,  after  recovery,  been  employed  as  steward,  and  had 
done  the  M'ork  remarkably  well.  It  may  be  said  here  that  the  number  of  persons  taken 
out  to  work  is  necessarily  somewhat  limited,  the  garden  being  so  small.  "With  a  farm,  a 
large  number  of  patients  could  be  employed  to  do  common  work. 

"  '  It  might,  at  first  sight,  be  supposed  that  the  number  of  feigners  would  be  large  in 
the  Auburn  Asylum,  since  its  comfort  would  be  favorably  commented  on  among  the  con- 
victs and  lead  some  to  simulate  insanity  for  the  purpose  of  becoming  patients.  Such  is 
not  now  the  case,  since  the  asylum's  reputation  for  pleasant  surroundings  is  coupled  with 
a  reputation  for  the  quick  perception  and  prompt  return  of  the  dissemblers  to  prison.  In 
this  connection  it  may  be  said  that  the  prison  authorities  have,  in  titnes  past,  taken  advan- 
tage of  the  nearness  of  the  asylum  to  transfer  feigners,  who  would  not  have  been  so  trans- 
ferred had  the  asylum  been  more  remote.  This  fact  appears  to  offset  the  apparent  advan- 
tage which  would  be  found  in  early  transferring  from  the  prison  to  an  asylum  close  by 
those  convicts  really  insane  whose  insanity  for  some  time  may  escape  notice  in  a 
prison.'  " 

Dr.  Walter  Channing,  in  a  recent  article  on  "  Buildings  for  Insane  Criminals,"*  says  : 
"  How  much  may  be  accomplished  by  proper  treatment  may  be  seen  at  Auburn,  where 
the  worst  class  of  the  insane  give  but  comparatively  little  trouble  and  are  Subjected  to  a 
minimum  of  mechanical  restraint,  and  yet  are  as  comfortable  and  contented  as  patients 
in  an  ordinary  hospital  for  the  insane.  We  find  the  patients  well  fed  and  clothed,  and 
receiving  the  most  thorough  medical  care;  but  combined  with  this  treatment  there  is 
exercised  an  amount  of  disciplinary  care,  without  being  obtrusive,  which  would  be  im- 
possible in  an  ordinary  hospital.  As  illustrations  of  this  I  may  mention  the  following 
examples:  wearing  a  uniform  dress,  which,  however,  is  not  a  uniform ;-j-  retiring  at  7 
P.M.,  summer  and  winter;  using  no  tobacco;  carrying  no  knives,  and,  as  a  rule,  using 
none  at  table ;  being  thoroughly  searched  when  entering  the  wards  from  out  of  doors ; 
using  no  furniture  in  the  room  besides  a  bed,  etc.  These  and  other  simple  regula- 
tions the  patients  readily  yield  to,  and  are  thereby  happier  themselves,  as  well  as  more 
manageable.  It  is  but  proper  to  state,  in  this  connection,  that  the  wards  of  the  Auburn 
Asylum  are  to-day  as  bright,  and  cheerful,  and  attractive  as  any  I  have  seen  in  twenty 
hospitals,  and  the  diet  better  than  is  furnished  in  some  State  hospitals." 

Dr.  Kirkbride'  s  Pennsylvania  Hospital  for  the  Insane. — The  Report 
of  the  Pennsylvania  Hospital  for  the  Insane,  under  the  able  manage- 
ment of  Dr.  Thomas  S.  Kirkbride,  to  whom  we  are  indebted  for  the 
report,  shows  that  it  began  in  1841,  with  97  patients,  received  from 
the  old  hospital,  which  was  established  in  1752,  and  that  since  its 
opening  in  1841  up  to  1882,  8480  patients  had  been  received.  Of 
these,  3825  have  been  restored  to  their  friends  cured,  2044  have  been 
discharged  in  various  states  of  improvement,  1098  left  without  ma- 
terial improvement,  and  1 115  died. 

The  last  report,  for  1882,  shows  that  at  the  end  of  188 1  there  were 

*  Read  at  the  .Conference  of  Charities  in  Chicago,  June  nth,  1879. 
I  Navy  blue  sack  coat,  gray  casbimere  pants  and  vest. —  C.  F.  M. 

13 


194  PSYCHOLOGICAL   MEDICINE. 

398  patients  in  the  institution.  During  1882,  193  patients  were  ad- 
mitted, and  183  were  discharged  or  had  died,  leaving  408  under  care 
at  the  end  of  the  year.  Total  number  of  patients  in  the  hospital 
during  the  year  was  591.  The  highest  number  at  any  time  was  431 ; 
the  lowest  was  385,  and  the  average  number  408.  There  were  dis- 
charged cured  during  1882,  66  patients;  much  improved,  22;  im- 
proved, 43  ;  stationary,  29 ;  died,  23.  Of  the  patients  discharged 
"  cured,"  22  were  residents  of  the  hospital  not  exceeding  three  months ; 
24  between  three  and  six  months;  13  between  six  months  and  one 
year,  and  7  for  more  than  one  year.  Of  the  "improved,"  16  were 
under  care  less  than  three  months;  9  between  three  and  six  months; 
9  between  six  months  and  one  year,  and  9  for  more  than  one  year. 

The  statistical  tables  of  this  institution  are  peculiarly  valuable,  as 
relating  to  over  eight  thousand  patients,  and  I  therefore  give  them 
for  their  intrinsic  value  and  for  the  conclusions  the  profession  may 
draw  from  their  study.  I  would  call  especial  attention  to  table  viii., 
showing  the  supposed  cause  of  insanity.  It  will  be  seen  that  ill- 
health,  intemperance,  mental  anxiety,  grief,  loss  of  friends,  etc.,  the 
puerperal  state,  religion,  excitement,  loss  of  property,  and  injuries  to 
the  head,  rank,  in  the  order  in  which  I  have  given  them,  as  causes  of 
insanity.  Doubtless  90  per  cent,  of  these  cases,  could  they  be  truly 
traced,  were  due  primarily  to  an  inherited  insane  taint.  The  3366 
cases  unascertained  would  naturally  all  come  under  this  head. 

To  the  remarks  of  Dr.  Kirkbride,  who  is  one  of  the  most  distin- 
guished authorities  on  mental  diseases  in  this  country,  I  would  call 
the  especial  attention  of  the  profession. 

Statistical  Tables. — The  tables  in  this  report  embrace  all  the  cases  received  into  the 
hospital  since  its  opening  in  its  present  location  on  the  first  day  of  1841.  The  number 
of  patients  included  in  the  tables  given  in  this  report  is  8673,  and  the  period  of  observa- 
tion is  forty-two  years. 

As  every  year  adds  to  the  number  of  patients  who  have  been  under  treatment,  so  it 
increases  the  value  of  the  tables,  which  are  prepared  with  as  much  care  as  possible. 
Much  of  the  information  on  which  these  are  based  must  necessarily  come  from  the  state- 
ments furnished  by  the  friends  of  the  patients ;  and,  without  much  caution  and  a  careful 
cross-examination,  there  is  often  a  great  possibility  of  being  led  into  error,  although  it 
may  be  unintentionally,  upon  the  reception  of  a  patient.  At  a  later  period  of  treatment, 
and  with  a  greater  familiarity  with  the  case,  it  is  often  quite  practicable  to  correct  these 
errors,  and  to  make  as  near  an  approach  to  entire  accuracy  as  possible.  Most  of  the- 
tables  are  merely  statements  of  facts,  about  the  accuracy  of  which  there  can  be  no  ques- 
tion, but  there  are  others  that  must  always  be  matters  of  opinion,  and  the  value  of  which 
must  depend  upon  the  care  with  whi^h  they  are  made,  and  the  ability  of  the  observer. 


TREATMENT   OF    INSANITY. 


195 


Table  I. — Showing  the  nujtiber  and  sex  of  the  ad?nissions  and  discharges 
since  the  opening  of  the  Hospital,  and  of  those  re/naining  at  the  end  of  the 
year. 


Admissions, 

Males. 

Females. 

Total. 

4669 
4486 

4004 

3779 

8673 
8265 

Discliarges, 

Remain, 

183 

225 

408 

Table  II. — Showing  the  ages  of  86'/^  patients  at  the  time  of  their  admission. 


M. 

F, 

T. 

M. 

F. 

T. 

Under  10  years,  .  ,  . 

2 

3 

,s 

Between  50  and  55,  .  . 

3.34 

262 

596 

Between  10  and  15, 

I^ 

19 

34 

"    55  and  60, 

225 

169 

394 

"    15  and  20, 

237 

225 

462 

"    60  and  65, 

166 

131 

297 

"    20  and  25, 

636 

S23 

IIS9 

"    65  and  70, 

92 

81 

i«3 

25  and  30, 

667 

617 

1284 

"    70  and  75, 

75 

75 

ISO 

30  and  35, 

622 

ci46 

1 168 

"    75  and  80, 

31 

21 

52 

35  and  40, 

662 

498 

1 1 60 

"    80  and  85, 

7 

12 

19 

"    40  and  45, 

477 

454 

931 

"    85  and  90, 

3 

I 

4 

"    45  and  50, 

418 

356 

774 

"    90  and  95, 

0 

I 

I 

196  PSYCHOLOGICAL  MEDICINE. 

Table  III. — Showing  the  ocacpation  of  4.66g  male  patients. 


Farmers, 

496 

Insurance  Agent, 

I 

Merchants, 

452 

Hairdressers.     . 

3 

Clerks, 

546 

Police  Officers, 

10 

Phj-sicians, 

103 

Machinists, 

74 

Lawyers,  .... 

112 

Plane-maker,     . 

I 

Clergymen, 

57 

Iron-masters,     . 

2 

Masons,     . 

ZZ 

Weavers,  . 

48 

Umbi-ella-makers, 

7 

Bricklayers, 

17 

Printers,    . 

51 

Brick-makers,    . 

9 

Teachers, 

56 

Sail-makers, 

7 

Officers  of  the  Anny, 

10 

Coopers,    . 

5 

"          "         Navy, 

17 

Jewellers, 

23 

Students,  . 

87 

Potters,      . 

3 

of  Medicine, 

23 

Chair  and  Cabinet-makers 

41 

of  Law,     . 

12 

Blacksmiths, 

48 

of  Divinit}', 

14 

Watchmakers,   . 

II 

Saddlers,  . 

17 

Hotel  Keepers, 

70 

Peddlers,  . 

21 

Second-hand  dealers, 

4 

Tobacconists,    . 

30 

Cap  Manufacturer,    . 

I 

Carpenters, 

155 

Locksmiths, 

4 

Bakers, 

23 

Millers,     . 

21 

Seamen  and  Watermen, 

76 

Glassblowers,    . 

4 

Planters,   . 

ZZ 

Wheelwrights,  . 

8 

Manufacturers, 

loS 

Gardeners, 

30 

Coachmen, 

9 

Chemists, 

5 

Druggists, 

44 

Print  Cutters,    . 

2 

Laborers,  . 

338 

Curriers,    . 

2 

Engineers, 

31 

Tailors,     . 

49 

Plasterers, 

20 

Shoemakers, 

109 

Bank  Officers,  . 

2 

Brokers,    ... 

17 

Conveyancers,  . 

12 

Waiters,    . 

4 

Bookbinders,     . 

19 

Stove-makers,  . 

3 

Hatters,     , 

12 

Dentists,  . 

4 

Rope-makers,    . 

3 

Victuallers, 

23 

Tinmen,    . 

25 

Soldiers  U.  S.  A.,       . 

19 

Painters,   . 

40 

Brewers,    . 

4 

Brush-makers,   . 

3 

Coach-trimmers, 

2 

Paper-hangers, 

4 

Auctioneers, 

3 

Boat-builder, 

I 

Plumbers, 

7 

Carvers,     , 

4 

Type  Founders, 

3 

Confectioners,  . 

14 

Telegraph  Operators, 

7 

Coach-makers,  . 

9 

Whip-maker,    . 

I 

Public  Officers, 

8 

Silversmiths, 

3 

Shipwrights, 

4 

Photographer,    . 

•     I 

Collectors, 

2 

Wire-worker,    . 

I 

Nurses, 

2 

Upholsterers,     . 

4 

Soap-maker, 

I 

Drovers,    . 

6 

Contractors, 

6 

Brass  Founder, 

I 

Authors,    . 

4 

Pattern-maker, 

I 

Editors,     . 

8 

Comb-maker,     . 

I 

Railroad  Conductor, 

I 

Grocers,    . 

9 

Apprentices, 

3 

Cigar-makers,    . 

2    • 

Musicians, 

6 

Glove-makers,  . 

3 

Coppersmith,     . 

I 

Errand  boys. 

4 

Tanners,    . 

8 

Engravers, 

7 

Artists, 

25 

Electrician, 

I 

Dyers, 

2 

i     Reporters, 

3 

Gold-beater, 

I 

No  occupation, 

1 

685 

TREATMENT   OF    INSANITY. 


197 


Table  IV.—. 

Showing 

^he  occupation 

of  4004  female  patients. 

Seamstresses  or  Mantua-makers, 

342          Dau^ 

^hiers  of  Author, 

I 

Storekeepers,     .         .         .         . 

28 

'               "Victuallers, 

5 

Attendants  in  stores, 

35 

'               Saddler, 

I 

Cigar-makers,    .          .         ,         . 

4 

'                Coach-makers, 

4 

Teachers, 

114 

'               Contractors, 

2 

Domestics, 

354 

'                Tinman, 

I 

Nurses, 

33 

'               Mason, 

I 

Artists,      . 

5 

'               Hatters, 

2 

Factory  Girls,   . 

21 

Publisher, 

I 

Physician, 

I 

'               Painters, 

4 

Sister  of  Charity, 

I 

'                Glassmakers, 

2 

Clerks,       . 

9 

'                Shipbuilders, 

3 

Actress,     . 

I 

'                Caterers, 

2 

School  Girls,     . 

3 

*                Grocer, 

I 

Hair-dresser,     . 

I         OftheiK 

^arried,  similarly  situatec 

,  were— 

Box-maker, 

I             Wivt 

s  of  Clerks, 

122 

Of  the  Single  females,  not  pursuing  a  reg 

" 

Teachers,  . 

25 

ular  occupation,  were — 

a 

Farmers,  . 

263 

Daicghters  of  Farmers, 

176                    " 

Brass  Founders 

4 

"                Merchants,  . 

239 

Gardeners, 

9 

"                Masons, 

4 

Saddlers,  . 

5 

"               Bank  Officers,      . 

10               " 

Printers,    . 

II 

"               Weavers, 

20               « 

Machinists, 

42 

'•               Laborers,     . 

41 

Masons,    . 

7 

"               Sea  Captains, 

6 

Painters,    . 

7 

"               Auctioneer, 

I               " 

Stage  Owners,  . 

2 

"                Innkeepers, 

12              " 

Cutler,       . 

I 

" .              Teachers,     . 

17 

Bank  Officers, 

16 

"                Carpenters, 

23 

Innkeepers, 

46 

"                Paper-makers, 

2 

Bookbinders, 

4    . 

"                Physicians,  . 

23 

Tinmen,    , 

5 

"               Planters, 

33 

Editors,     . 

8 

"                Watchmaker, 

I               " 

Plasterers, 

5 

"                Curriers, 

3 

Engineers, 

22 

Clerks, 

42 

Artists,      . 

13 

"                Engineers,   , 

3 

Bricklayers, 

2 

"                Clergymen, 

27              " 

Paper-makers, 

3 

Miller, 

I              « 

Collectors, 

5 

Public  Officers,    . 

24 

Brick-makers,  . 

8 

"               Officers  of  Army, 

2              " 

Seamen,    . 

14 

Navy, 

I              « 

Merchants, 

273 

"                Lavsryers, 

32 

Physicians, 

30 

"               Machinists, 

9 

Lawyers  and  Ju 

dges. 

59 

"                Bricklayers, 

2              " 

Shoemakers, 

46 

"                Chairmakers, 

2              " 

Hatters,     . 

6 

"                Manufacturers,     . 

21               " 

Cabinet-makers 

20 

"               Tailors, 

8 

Laborers, 

229 

"               Watermen,  . 

2               " 

Grocers,    . 

12 

"                Bakers, 

7 

Clergymen, 

38 

"                Printers, 

II              " 

Tobacconists,     . 

12 

"               Shoemakers, 

6              " 

Weavers, 

21 

Druggists,    . 

4 

Sea  Captains,    . 

5 

"                Artists, 

4 

Victuallers, 

12 

"               Brick-maker, 

I                " 

Brush-makers,  . 

2 

"                Blacksmiths, 

2               " 

Tailors,     . 

32 

"                Musician,     . 

I               " 

Millers,     . 

12 

"               Dentists, 

4 

Police  Officers, 

II 

"               Tanner, 

I               " 

Carpenters, 

57 

198 


PSYCHOLOGICAL   MEDICINE. 


Table  IV. — Co7itiniied. 


Wives  of  Druggists, 

16 

Widows  of  Shoemakers,   . 

27 

"             Huckster, 

I 

"             Clerg}'men, 

7 

"              Planters,    . 

15 

"              Farmers, 

72 

"              Paper-hanger,    . 

I 

"              Coopers, 

3 

"             Ship-builder,     . 

I 

"             Laborers, 

44 

"              Livers'-keeper,  . 

I 

"             Manufacturers 

16 

"             Peddlers,  . 

8 

''              Law3-ers, 

12 

''             Coachmen, 

4 

"              Carpenters, 

8 

"             Manufacturers, 

74 

"              Clerks,    . 

19 

"             Brokers,    . 

5 

"              Tanners, 

2 

"              Tanners,    . 

14 

"             Teachers, 

2 

"             ^lusicians, 

4 

"              Planters, 

6 

"              Conveyancers,   . 

8 

''              Bricklayers, 

3 

"              Officers  of  Array, 

13 

"             Painters, 

3 

"                   "            Navy, 

4 

"             Seamen, 

9 

"              Plumbers, 

3 

"              Engravers, 

2 

''              Blacksmiths,      . 

17 

''              Engineers, 

7 

"              Bakers,      . 

6 

''              ]\Iachinists, 

6 

Waiters,     . 

3 

"              Masons,  . 

2 

''              Confectioners,   . 

4 

"              Printer,    . 

I 

"              Hairdressers,     . 

2 

"              Blacksmiths, 

3 

"              Contractors, 

7 

Bakers,    . 

5 

"             R.R.  Conductors,       . 

9 

"              Druggists, 

4 

"             Dentists,    . 

6     ' 

''              Musician, 

"             Watchmakers,  . 

6 

"              Interpreter, 

"             Public  Officers, 

17 

"              Tailor,     , 

"             Brewers,    . 

4 

"              Dentists, 

2 

"              Optician,  . 

I 

''              Tinman, 

"              Ironmasters, 

3 

"              Confectioner, 

"              Perfumer, 

I 

'«             Silversmith, 

"             Gold-beater,      . 

I 

''              Barber,    . 

"              Jewellers, 

2 

''              Brickmaker, 

"             Architect, 

I 

''              Coachman, 
''              Carriagemaker 

s, 

2 

Of  the  Widows,  similarly  situated. 

"              Army  Officer, 

were — 

"              Plasterer, 

Widows  of  Merchants, 

78 

"             Tobacconist, 

"              Physicians, 

17 

"             Weaver, 

Public  Officers, 

12 

"             Contractor, 

"              Sea  Captains,  . 

8 

''              Conveyancer, 

I 

"             Hotel  Keepers, 

6 

Peddler, 

Table  V. — Showing  the  number  of  single,  mai'ried,  widows,  and  widowers 

i?i  Sdyj  patients. 


Females. 

Total. 

1645 

3917 

1866 

4016 

493 

493 

247 

Single, 
Married, 
Widows, 
W^idowers, 


Males. 


2272 
2150 

247 


TREATMENT    OF    INSANITY. 


199 


Table  VI. — Showing  the  nativity  of  86yj  patients. 

Nat 

ves  of  Pennsylvania,  . 

4622           Nat 

ives  of  Scotland, 

56 

New  Jersey,     . 

393 

'              Ireland,   . 

1079 

Delaware, 

209                ' 

'              Germany, 

465 

Maryland, 

253 

Poland,    . 

10 

Virginia, 

H3 

'              Prussia,    . 

18 

North  Carolina, 

73 

'              Switzerland,     . 

10 

South  Carolina, 

61 

'              Bermuda,  W.  I., 

3 

Georgia,  . 

40 

'              Jamaica,         " 

2 

Alabama, 

19 

'             St.Domingo, " 

4 

Tennessee, 

31 

'             Barbadoes,     " 

4 

Indiana,  . 

15 

'              Cuba,               " 

18 

Kentucky, 

40 

'              Guadaloupe, " 

I 

Dist.  of  Columbia, 

24 

'              Martinique,    " 

I 

Maine,     . 

22                ' 

'              St.  Croix,       " 

I 

Massachusetts, 

99                ' 

'             St.  Thomas,  " 

3 

Connecticut,     . 

49                ' 

'             Island  of  Madeira,   . 

I 

Missouri, 

20                ' 

'             Isle  of  Man,    . 

I 

Ohio, 

64 

*              Spain, 

3 

New  Hampshire, 

14 

'              Italy, 

6 

Louisiana, 

26 

'              Denmark, 

4 

Rhode  Island, 

17 

Holland, 

5 

New  York, 

288 

'              Russia,     . 

I 

Mississippi, 

14                ' 

'              Austria,   . 

6 

Vermont, 

7 

'              Bavaria,  . 

4 

West  Virginia, 

6 

'             Venezuela,  S.  A.,     . 

I 

Michigan, 

4 

'              Norway,  . 

I 

Iowa, 

3 

'              Japan, 

I 

Texas, 

5 

'             Costa  Rica, 

2 

Illinois,   . 

14 

'             St.  Kitts, 

2 

Florida,    . 

5 

'             Mexico,  . 

I 

Wisconsin, 

4 

«              Brazil,      , 

2 

Sicily, 

I               ' 

'             Belgium, 

I 

Nova  Scotia,    . 

2               ' 

'              Buenos  Ayres, 

I 

Canada,  . 

19 

'              China, 

I 

France,    . 

27 

'             Ceylon,    . 

I 

'             England, 

348           Bor 

n  at  sea,       .... 

I 

Table  VII. — Showi 

ng  the  residence  of  86'/ j  patients. 

Residents  of  Pennsylvania, 

7052          Resid 

ents  of  New  York,   , 

207 

ii 

New  Jersey, . 

304 

'               Florida, 

6 

a 

Delaware, 

192                  ' 

'               Wisconsin,    . 

3 

" 

Maryland, 

192                 ' 

'               California,    . 

S 

it 

Virginia, 

78 

'               Oregon, 

I 

(( 

West  Virginia, 

9 

'               Minnesota,    . 

4 

" 

Dist.  of  Columbia, 

41 

'               Kansas. 

5 

" 

North  Carolina,    . 

67, 

'               Montana, 

2 

" 

South' Carolina,    . 

n 

'               Colorado, 

2 

li 

Georgia, 

39 

'               Nebraska,     . 

I 

" 

Alabama, 

23 

'               Jamaica,  W.  I.,     . 

2 

it 

Louisiana, 

47 

'               Barbadoes,   " 

4 

" 

Tennessee, 

22            ' 

Cuba, 

14 

" 

Kentucky, 

25 

'               St.  Croix,      " 

I 

a 

Arkansas, 

4 

'              St.  Thomas,  " 

4 

" 

Mississippi, 

IS 

'               Island  of  Madeira, 

I 

" 

Vermont, 

5 

'               Germany, 

3 

ci 

Texas, . 

14 

'               Venezuela,  S.  A., 

2 

(C 

Illinois, 

28 

'               England, 

7 

" 

Michigan, 

10            ' 

'              Norway, 

2 

" 

Ohio,    . 

61 

'               Costa  Rica,  . 

2 

" 

Indiana, 

18 

'               Mexico, 

3 

•  ( 

Missouri, 

zz              ' 

'               Canada, 

9 

« 

Massachusetts, 

24 

'               Japan,  .  ='       . 

I 

«' 

New  Hampshire, . 

I                  * 

'              Nova  Scotia, 

I 

(f 

Iowa,   . 

9 

«               Brazil, 

-2 

" 

Connecticut, 

16 

'               Italy,    . 

I 

<( 

Maine, 

3                  ' 

'              Sandwich  Islands, 

I 

11 

Rhode  Island, 

8 

200 


PSYCHOLOGICAL   MEDICINE. 


Table  VIII. — Showing  the  supposed  causes  of  insanity  in  86^3  cases. 


Ill  health  of  various  kinds, 
Intemperance, 
Loss  of  property,  . 
Dfead  of  poverty. 
Disappointed  affections, 
Intense  study, 
Domestic  difficulties. 
Fright,  .... 
Grief,  loss  of  friends,  etc., 
Intense     application    to 

business,     . 
Religious  exciterhent,    . 
Political  excitement, 
Metaphysical      specula- 
tions. 
Want  of  exercise. 
Engagement  in  duel, 
Disappointed  expectat'ns. 
Nostalgia, 
Stock  speculations. 
Violent  boating  exercise. 
Want  of  employment,    . 
Mortified  pride. 


M. 

F. 

T. 

864 

746 

1610 

798 

65 

863 

233 

55 

2S8 

4 

3 

7 

33 

68 

lOI 

41 

13 

54 

53 

120 

^1Z 

20 

55 

75 

90 

314 

404 

73 

19 

92 

9b 

147 

243 

14 

14 

I 

I 

6 

2 

8 

I 

I 

14 

22 

36 

.  .  . 

10 

10 

2 

2 

I 

I 

53 

3 

56 

2 

I 

3 

Celibacy, 

Anxiety  for  wealth. 
Use  of  opium. 
Use  of  tobacco, 
Lead  poisoning,     . 
Use  of  quack  medicines 
Puerperal  state, 
Lactation  too  long  con 

tinned, 
Uncontrolled  passion. 
Tight-lacing, 
Injuries  of  the  head. 
Masturbation, 
Mental  anxiety. 
Exposure  to  cold,  . 
Exposure  to  direct  rays 

of  the  sun. 
Exposure  to  intense  heat, 
Exposure  in  army, 
Old  age. 
Sudden     acquisition    of 

wealth. 
Unascertained, 


M. 


116 

96 

193 

5 

79 
I 


1730 


319 


14 


7 

•5 

334 


7 
1636 


T. 

I 

3 
35 
17 

I 

4 
319 

14 

13 

I 

123 

lOI 

527 
6 

82 
2 
8 
7 

T 

3366 


Table  IX. — Showing  the  ages  at  which  insanity  first  appeared  in  86yj 

patients. 


M. 

F. 

T. 

M. 

F. 

T. 

Under 

10  years,  . 

21 

6 

27 

Between 

50  and  55, 

232 

199 

431 

Between  10  and  15, 

73 

72 

14s 

55  and  60,   . 

163 

I3« 

301 

15  and  20, 

447 

.375 

822 

60  and  65, 

116 

87 

203 

20  and  25, 

801 

70s 

1506 

65  and  70, 

55 

37 

92 

25  and  30, 

809 

703 

1512 

70  and  75,   . 

30 

28 

5« 

30  and  35, 

574 

5S2 

1 126 

75  and  80, 

16 

9 

25 

35  and  40, 

S82 

426 

1008 

80  and  85, 

3 

10 

13 

40  and  45, 

418 

3«4 

802 

85  and  90, 

I 

I 

45  and  50, 

328 

273 

601 

Table  X. — Shoiving  the  forms  of  disease  for  which  8 6"/ j  patients  wet'e 

admitted. 


Mania, 
Melancholia, 
Monomania, 
Dementia,     . 
Delirium,      .     ^ 


Males. 

Females 

Total. 

1996 

1899 

3895 

1063 

I32I 

2384 

705 

447 

1152 

890 

332 

1222 

15 

5 

20 

TREATMENT   OF   INSANITY. 


20 1 


Table  XL — Showing  the  duration  of  the  disease  at  the  time  of  admis- 
sion in  862J  patients. 


Males. 

Females 

Total. 

Not  exceeding  3  months,       ....... 

2039 

2173 

4212 

Between  3  and  6  months, 

404 

339 

743 

"          6  months  and  one  3 

^ear, 

596 

467 

1063 

"         I  and    2  years, 

640 

396 

1036 

"         2  and    3     " 

324 

181 

505 

"         3  and    4     " 

179 

no 

289 

"         4  and     5     " 

109 

73 

182 

"          5  and  10     " 

201 

142 

343 

"        10  and  15     " 

75 

57 

132 

"       15  and  20     " 

34 

30 

64 

"        20  and  25     " 

34 

17 

51 

"       25  and  30     " 

16 

10 

26 

30  and  35     " 

7 

5 

12 

"       35  and  40     " 

5 

5 

"       40  and  45     " 

4 

3 

7 

"       45  and  50     " 

1 

I 

2 

"        55  and  60     " 

I 

I 

Table  XII. — Showing  the  nurnber  of  the  attack  in  86'jj  cases. 


M. 

F. 

T. 

In  the  periodical  cases, 

M. 

F. 

T. 

First  attack,    . 

3453 

2820 

6273 

loth  10  m.  7  f.,  nth  5  m.  4  f., 

15 

II 

26 

Second   " 

677 

713 

1390 

I2th  4  m.  3  f.,  13th  3  m.  2  f., 

7 

5 

12 

Third      " 

212 

249 

461 

14th  3  m.  3  f.,  15th  I  m.  I  f.. 

4 

4 

8 

Fourth    " 

"5 

95 

210 

i6th  I  m.,  17th  2  m.,    . 

3 

■\ 

Fifth       " 

51 

52 

105 

i8th  4  m.,  19th  2  m.,   . 

6 

6 

Sixth 

66 

19 

85 

20th  and  2ist  each  i  m.  and  I  f.. 

2 

2 

4 

Seventh  " 

32 

7 

29 

22d  I  m.,  and  to  26th  each  I  f.,    . 

I 

5 

6 

Eighth    « 

14 

10 

24 

27th  2  f.,  29th  if.,. 

3 

3 

Ninth      " 

9 

5 

14 

30th,  31st,  32d,  33d,  each  i  f., 

4 

4 

Table  XIII. — Showing  the  state  0/826^  patients  who  have  been  discharged 
or  died — their  sex,  and  the  forms  of  disease  for  which  they  were  admitted. 


.2 

0) 

0 

n! 

[A 

X. 

rt 

B 

"3 

S 

"3 

.2 
'3 

C 

0 

c 
0 

C 
B 

3 

Cured, 

§ 

fe 

EH 

S 

S 

s 

P 

0 

1975 

I916 

3891 

2157 

1077 

537 

117 

3 

Much  improved,  , 

262 

400 

662 

277 

249 

92 

44 

Improved,    . 

817 

630 

1447 

503 

427 

256 

261 

Stationary,  . 

771 

3S6 

II27 

369 

265 

I3« 

354 

I 

Died,  .... 

661 

477 

II38 

479 

241 

45 

357 

16 

202 


PSYCHOLOGICAL    MEDICINE. 


Table  XIA^. — Showing  the  Jiumber  of  admissions,  discharges ,   cures,  and 
deaths  in  each  month  since  the  opening  of  the  hospital. 


Admissions. 

Discharges. 

Cures. 

Deaths. 

1st  month, 

679 

743 

309 

109 

2d         " 

645 

524 

249 

84 

3d       - 

766 

614 

280 

90 

4th       « 

855 

635 

294 

103 

5th       " 

874 

744 

341 

no 

6th      " 

829 

705 

333 

72 

7th      " 

728 

782 

371 

102 

8th      " 

6S7 

728 

341 

"5 

9th      " 

660 

716 

346 

97 

loth      " 

680 

737 

373 

89 

nth      " 

637 

678 

320 

83 

i2lh      " 

632 

659 

334 

84 

Evening  Entertaintnents. —  Occupation  and  A?nusement  of  the  Patients. — The  year 
just  closed  has  made  a  record  quite  equal  to  any  of  its  predecessors  in  regard  to  the  mat- 
ters coming  under  the  heading  of  this  section  of  the  report  for  1882.  None  of  the  old 
modes  of  amusement,  occupation,  or  evening  entertainments  have  been  abandoned  or 
lessened  in  frequency,  while  several  new  ones  have  been  introduced,  to  the  great  grati- 
fication of  those  for  whose  benefit  they  were  originally  provided.  This  year,  it  may  be 
said,  with  some  allowable  pride,  is  the  fourteenth,  during  which,  at  one  department,  there 
has  not  been  the  omission  of  a  single  evening,  and  almost  the  same  is  true  of  the  other, 
during  the  nine  months  which  have  always  been  regarded  as  the  extent  of  the  regular 
course.  Beyond  the  fact  of  this  work  having  been  done,  it  is  pleasant  to  know  that, 
with  very  few  exceptions,  there  has  been  a  general  recognition  of  its  value,  and  that  its 
performance  has  been  regarded  as  involving  no  more  labor  than  that  of  carrying  out  the 
most  ordinary  daily  duties  of  the  institution.  At  the  department  for  males  all  the  varie- 
ties of  active  outdoor  exercise,  and  the  different  games  heretofore  used,  have  been  steadily 
resorted  to,  while  within  doors  everything  has  been  introduced  that  seemed  to  be  available 
and  likely  to  make  a  stay  in  the  hospital  less  irksome.  At  the  department  for  females, 
besides  all  the  customary  modes  of  occupation  and  amusement,  special  sewing-classes 
have  been  introduced  by  ladies  who  were  here  for  the  benefit  of  their  own  health,  and 
in  a  manner  which  has  given  particular  interest  to  them,  among  their  fellow-patients. 

The  modelling  in  clay,  under  the  direction  of  J.  Liberty  Tadd,  has  been  a  very  success- 
ful experiment,  and  some  of  the  products  of  that  workroom  have  been  most  satisfactorily 
successful.  Those  who  have  taken  instruction  in  oil-painting,  under  the  direction  of  the 
same  able  artist,  have  also  shown  the  value  of  all  of  this  class  of  occupations,  and  some 
patients  have  developed  a  capacity  for  that  kind  of  work  that  had  not  been  supposed  to  exist. 
In  summer  the  successful  cultivation  of  flowers  by  the  ladies  in  the  garden  placed  under 
their  immediate  control,  was  very  satisfactory,  and  a  source  of  great  pleasure  to  those 
who  have  thus  spent  hours  of  many  days  in  this  form  of  employment  in  the  open  air. 

To  the  ladies  who  originated  all  of  these  forms  of  occupation,  and  whose  zealous  prose- 
cution of  them  induced  so  many  to  unite  with  them  in  these  pleasant  modes  of  passing 
the  time,  we  feel  under  great  obligation  for  the  good  results  of  their  intelligent  sugges- 
tions and  active  participation  in  the  work. 

There  has  been  a  steady  effort  to  increase  the  amount  of  time  spent  in  the  open  air,  and 
in  suitable  exercise,  by  all  patients  whose  physical  condition  would  enable  them  to  work, 


TREATMENT    OF    INSANITY.  203 

ride,  or  walk.  The  kindness  of  our  friends  has  increased  the  number  of  our  vehicles  for 
riding,  and  we  hope  that  the  number  of  suitable  horses  and  ponies  will  also  be  made 
greater  from  the  same  source,  while  our  roads,  we  trust,  will  gradually  be  made  just  as 
good  as  their  proper  construction  can  make  them. 

A  small  gift  from  a  friend  for  the  special  purpose,  enabled  us  to  make  a  beginning  of 
having  music  on  the  lawns  in  the  summer  afternoons,  or  in  the  evenings  during  the 
officers'  tea  parties,  and  which  gave  so  much  pleasure  to  the  large  number  who  wea-e 
thus  enabled  to  have  this  enjoyment  while  in  the  open  air,  that  it  is  hoped  hereafter 
there  will  be  a  material  extension  of  this  mode  of  passing  a  portion  of  the  summer 
days,  when  the  patients  generally  can  be  out  of  doors  and  get  equal  benefit  from  it. 

To  those  not  familiar  with  the  ordinary  routine  of  our  evening  entertainments,  it 
may  be  mentioned  that  they  embrace,  besides  whatever  novelties  we  can  secure,  lec- 
tures, readings,  concerts,  exhibitions  of  very  fine  dissolving  views,  gymnastic  exercises, 
officers'  tea  parties  once  a  week  during  the  entire  year,  and  whatever  else  our  means 
and  the  kindness  of  our  friends  may  place  at  our  disposal. 

Dr.  Kirkbride's  remarks  on  the  necessity  for  prompt  treatment  are 
especially  valuable,  and  are  as  follows : 

While  there  are  so  many  causes  for  feelings  of  gratification  at  what  has  been  done, 
it  must  be  acknowledged  that  there  is  abundant  evidence  of  losses  sustained  by  a  ne- 
glect to  adopt  a  prompt  course  of  judicious  management  for  those  who  are  suffering 
from  forms  of  mental  disease,  that  when  neglected,  are  pretty  sure — sooner  or  later 
— to  lead  to  results  of  the  most  melancholy  character.  It  is  certain,  too,  that  while 
so  many  of  the  insane  are  permitted  to  wander  at  large,  unprotected  and  uncared 
for,  there  will  be  not  only  a  steadily  increasing  list  of  incurable  patients,  but  there  will 
also  be  a  daily  record  of  melancholy  events,  which  a  rational  course  of  care  would, 
probably,  have  prevented.  As  long  ago  as  twenty-seven  years,  after-  careful  obser- 
vation, the  writer  of  this  report  ascertained  that,  in  a  particular  year,  the  number  of 
persons  whose  lives  were  sacrificed  or  jeopardized  by  the  insane,  who  were  allowed 
to  be  at  large,  in  the  United  States,  was  equal  to  those  lost  by  all  its  railroad  acci- 
dents. Since  that  time  the  extension  of  railroads  has  made  the  accidents  connected 
with  them  undoubtedly  increase  in  a  greater  ratio  than  those  that  have  come  from  the 
course  of  persons  responsible  for  the  care  of  the  insane,  but  neglectful  of  their  obvious 
duties ;  but  even  now,  any  one  who  will  read  for  a  short  time  the  regular  daily  summaries 
of  such  occurrences,  and  of  the  accidents  throughout  the  country  that  may  be  found  in 
some  of  our  newspapers,  will  be  astounded  not  only  at  their  number,  but  at  the  horrible 
character  of  many  such  events  detailed  there.  Among  these,  it  is  hardly  necessary  to  say, 
are  intended  to  be  included  a  large  proportion  of  the  cases  of  suicide,  which  are  clearly 
the  results  of  disease,  and  which,  with  proper  care,  would  have  been  prevented  and  in  all 
human  probability  these  unfortunates  would  have  been  restored  to  their  families,  relieved 
of  this  dreadful  propensity. 

A  general  knowledge  in  the  community  of  facts  like  these,  as  well  as  of  the  risks  of 
delaying  treatment  till  the  probable  period  of  its  being  successful  has  passed,  would  lead 
those  having  control  of  families  to  seek  early  counsel  from  their  medical  advisers  on  the 
occurrence  of  symptoms  of  mental  aberration,  and  these  could  not  fail  to  feel  the  respon- 
sibility of  promptly  adopting  the  only  course  that  is  likely  to  give  protection  equally  to 
patients,  their  families,  and  the  community. 

It  has  been  common  to  urge,  in  documents  coming  from  this  institution,  not  only 
the  importance  of  a  more  thorough  study  of  mental  diseases  in  the  medical  schools, — 


204  PSYCHOLOGICAL   MEDICINE. 

because  it  is,  in  a  large  majority  of  cases,  from  the  family  physician  that  counsel  is 
first  asked  on  the  indication  of  such  a  trouble, — but  also,  that  in  colleges  and  all  the 
higher  institutions  of  learning,  as  well  as  in  ordinary  schools,  there  should  be  taught  at 
least  a  general  idea  of  the  functions  of  the  brain,  the  courses  of  life  likely  to  lead  to 
their  disturbance,  as  well  as  those  that  would  probably  maintain  them  in  their  integrity, 
some  of  the  indications  of  commencing  disorder,  the  importance  of  prompt  treatment, 
and  especially  of  steady  perseverance  in  it,  under  wise  counsel,  when  once  undertaken. 

If  such  knowledge  were  generally  diffused,  it  would  be  not  only  directly  advanta- 
geous to  those  who  are  suffering  from  mental  disorders,  but  it  would  put  an  effectual 
check  to  the  extravagant  plans  constantly  urged  upon  the  attention  of  legislatures, 
not  only  in  regard  to  the  construction  of  hospitals,  but  to  their  government  and  to 
various  details,  which  properly  can  only  be  left  to  the  executive  authorities  of  such 
institutions.  Legislators,  then,  would  have  no  difficulty  in  deciding  for  themselves  on 
the  pretensions  of  those  whose  schemes  have  nothing  but  novelty  for  their  recommenda- 
tion, and  which  are  opposed  by  the  results  of  all  careful  experience. 

No  one  who  has  had  much  to  do  with  giving  counsel  to  those  who  have  had  their 
dearest  friends  threatened  with  this  class  of  disorders,  or  who  are  themselves  actually 
sufferers  from  some  form  of  them,  but  must  have  recognized  how  much  distress  would 
have  been  saved  to  all  concerned,  by  a  veiy  moderate  amount  of  such  sound  knowledge 
of  the  malady  as  has  been  referred  to,  as  well  as  a  general  idea  of  the  kind  of  treatment 
in  hospitals,  that  to  be  successful,  is  often  unavoidable,  and  some  of  the  reasons  for  its 
adoption. 

There  is  a  picture  constantly  to  be  met  with  where  individuals  with  more  than  the 
average  mental  intelligence  and  a  general  familiarity  with  ordinary  topics  and  business, 
come  for  counsel,  with  feelings  of  depression  and  utter  hopelessness  far  beyond  what  are 
commonly  connected  with  the  occurrence  of  any  ordinary  malady.  Acknowledging  a 
profound  ignorance  of  the  whole  subject,  the  declaration  is  made  that  the  existence  of 
such  a  trouble  is  wholly  unaccountable,  no  one  in  the  family  having  ever  suffered  from 
any  mental  disorder,  and,  while  prepared  to  make  every  sacrifice  to  secure  the  restora- 
tion of  the  patient,  before  doing  so  they  very  properly  desire  some  explanation  of  the 
nature  of  the  disease,  the  chances  of  a  recovery,  and  the  reasons  for  plans  of  treatment  so 
different  from  what  are  commonly  adopted  in  the  management  of  ordinary  sickness. 

Then  come  the  dread  of  leaving  home  and  losing  all  the  kind  attentions  there  com- 
monly given,  dislike  to  the  idea  of  entering  an  institution  of  the  character  of  which  little 
is  known,  and  where  it  is  supposed  all  classes  of  invalids  are  mingled  together ;  and  all 
this  is  accompanied  by  an  utter  inability  to  comprehend  how,  under  any  classification,  one 
person  with  a  disordered  mind  can  fail  to  be  of  disadvantage  to  another  if  living  in  the 
same  building,  no  matter  how  extensive  it  may  be  or  how  complete  may  be  the  arrange- 
ments for  a  thorough  separation  of  the  different  classes  of  patients. 

To  those  who  have  such  impressions  and  such  a  want  of  knowledge  on  the  entire  sub- 
ject, it  can  only  be  answered  that  insanity  is  a  disease  from  which  no  one,  under  certain 
circumstances,  can  claim  exemption ;  that  if  no  individual  belonging  to  a  family  has  ever 
had  such  a  form  of  sickness  it  is  only  a  matter  for  profound  gratitude,  and  that  such  a 
degree  of  permanent  good  fortune  can  hardly  be  expected  to  continue  indefinitely. 

By  many  heredity  is  regarded  as  the  prevalent  cause  for  the  development  of  mental  dis- 
orders, and  that  without  it  there  is  little  danger  of  its  occurrence.  Although  hereditary 
influence  is  often  an  important  element  in  the  production  of  mental,  as  of  other  diseases, 
still  the  extent  of  it  has  unquestionably  been  often  greatly  exaggerated.  That  this  is  so 
may  reasonably  be  inferred  from  the  fact  that  of  the  first  5381  cases  suffering  from  a 


TREATMENT   OF    INSANITY.  205 

primary  attack  of  insanity  admitted  here,  there  were  only  434  in  whom  there  could  be 
traced  any  hereditary  influence  worthy  of  record. 

It  should  be  a  comfort,  too,  for  such  inquirers  to  be  assured,  as  our  experience  here 
fully  justifies  us  in  saying,  that  where  simple,  uncomplicated  cases  of  insanity  are  properly 
and  promptly  treated,  and  the  treatment  duly  persevered  in,  they  are  just  as  curable  as 
are  other  ordinary  serious  disorders,  and  that  when  entirely  cured,  where  a  thorough 
obedience  to  natural  laws  and  common  sense  are  subsequently  observed,  there  is  no  more 
reason  to  anticipate  a  return  of  the  disease  than  there  would  be  in  other  maladies  under 
similar  circumstances. 

The  day  should  now  be  passed  when  any  one  of  intelligence  and  cultivation  should 
regard  it  as  a  reproach  to  have  suffered  from  impairm.ent  of  health  and  to  have  resorted 
for  treatment  to  an  institution,  without  which  course,  there  was  good  ground  to  believe, 
the  chances  of  restoration  would  have  been  greatly  diminished.  As  there  could  be  no 
reproach  in  suffering  from  an  illness  for  which  there  was  no  responsibility,  so,  very  clearly, 
there  could  not  be  in  taking  advantage  of  every  means  for  the  restoration  of  one's  health 
that  the  most  widely-extended  experience  had  given  reason  to  believe  would  be  suc- 
cessful. 

Beyond  this,  if  it  were  wanted  to  discover  those  who  had  been  sufferers  from  this  class 
of  affections  and  had  been  restored  to  health  and  usefulness  through  hospital  treatment, 
there  need  be  no  difficulty  in  finding  such  among  the  best  and  most  cultivated  men  and 
women  of  the  land,  and  whose  hospital  experiences  had  rendered  them  prepared  for  a 
wider  degree  of  enlightened  usefulness  than  they  could  otherwise  have  possessed. 

Another  important  result  of  careful  investigation  that  should  always  be  given  to  those 
who  are  seeking  information  on  the  subject  is  that  universal  experience  has  shown  that 
the  most  important  elements  for  securing  a  restoration  to  health  are  the  prompt  resort  to 
an  intelligent  course  of  treatment  and  a  steady  persistence  in  it  till  the  complete  recovery 
of  the  patient.  While  they  may  be  assured  that  it  is  not  necessary  that  every  person  who 
is  suffering  with  an  unsound  mind  should  leave  home  for  treatment,  there  can  be  no  ques- 
tion but  that  the  general  experience  is  positive  that,  for  a  very  large  number  of  those  who 
are  thus  affected,  this  is  a  painful  necessity,  and  must  be  joined  to  the  patient's  being 
placed  under  the  care  of  those  who  have  made  a  special  study  of  the  whole  subject, 
strangers  though  they  are  likely  to  be,  if  it  is  desired  to  give  them  the  best  chances  for  a 
restoration. 

So,  when  they  plead  for  a  mode  of  care  in  their  homes  and  with  their  families,  they 
are  to  be  reminded  that  "home  treatment"  and  "family  care,"  with  all  the  kind  atten- 
tions which  are  connected  with  such  a  mode  of  providing  for  the  unsound  of  mind,  have 
almost  always  been  tried  and  have  failed  before  the  removal  from  home  is  even  brought 
up  for  consideration.  So,  too,  as  among  the  results  of  the  disease  itself,  they  need  hardly 
to  be  told,  is  often  found  an  utter  want  of  appreciation  of  the  kindest  attentions  from  the 
dearest  of  friends,  and  all  the  blessings  of  home  and  its  surroundings  are  as  likely  as  not 
to  be  completely  ignored  or  not  appreciated.  It  may  also  be  asked  why,  when  no  hesi- 
tation is  felt  in  leaving  home  to  secure  perfect  rest,  and  change  of  scene,  climate,  and 
occupation,  when  these  have  been  found  beneficial  in  other  maladies,  those  who  suffer 
from  mental  illness  should  not  avail  themselves  of  any  change,  although  different  in  kind, 
which  rarely  involves  such  an  expenditure  of  means,  risk,  and  anxiety,  and  the  results 
of  which  have  been  found  to  be  at  least  as  favorable  by  an  almost  universal  experience 

Many  of  those  who  thus  come  for  counsel  have  never  even  seen  the  interior  of  a  hos- 
pital, and  have  derived  most  of  their  ideas  in  regard  to  such  institutions,  not  only  of  their 
management  but  their  construction,  from  works  of  fiction  or  the  sensational  articles  so 
often  found  in  certain  portions  of  the  public  press,  bringing,  therefore,  with  them  preju- 


2o6  PSYCHOLOGICAL    MEDICINE. 

dices  of  the  most  extravagant  kind.  Before  such  as  these  are  allowed  to  decide  upon 
placing  their  friends  under  the  care  of  an  institution,  they  should  be  shown  through  the 
different  parts  of  the  building,  have  its  arrangements  explained,  and  be  enabled  to  see  for 
themselves  that  the  patients  are  classified  so  as  to  do  most  good,  or,  at  any  rate,  the  least 
possible  harm,  to  each  other,  and  that  this  mode  of  separation  may  be  made  almost  as  com- 
plete as  that  of  families  living  in  contiguous  buildings  of  a  square  in  a  city,  where  all  are 
liable  to  meet  in  their  walks  in  the  streets  or  in  the  pai'ks,  at  places  of  amusement,  lec- 
tures, or  religious  services,  but  not  otherwise  unless  voluntarily. 

In  regard  to  entering  hospitals,  it  is,  indeed,  a  matter  of  surprise  that  patients  are  often 
so  far  in  advance  of  their  families  and  friends  in  indicating  the  proper  course  to  be  pur- 
sued on  the  occurrence  of  a  case  of  insanity,  and,  after  recovery,  there  is  nothing  more 
pleasant  than,  as  is  often  the  case,  to  have  those  who  have  been  so  fortunate  as  to  secure 
this  result  from  hospital  care,  ask  that,  should  they  ever  have  a  recurrence  of  the  disease, 
they  should  be  again  promptly  placed  under  the  same  form  of  treatment. 

Report  of  Statistics  of  the  Hartford  Retreat  for  the  Insane,  Hartford, 
Conn. — The  Fifty-ninth  Annual  Report  of  the  Retreat  for  the  Insane 
at  Hartford,  Conn.,  for  which  we  are  indebted  to  Dr.  Henry  P.  Stearns, 
the  superintendent,  shows  :  that  on  the  31st  day  of  March,  1882,  the 
vvrhole  number  in  the  Retreat  was  122, — 58  men  and  64  women. 
There  were  78  admissions  during  the  year.  There  were  74  dis- 
charges and  9  deaths.  The  whole  number  under  treatment  during 
1882  was  200;  there  were  discharged  recovered,  26;  much  improved, 
1 1  ;  improved,  6 ;  stationary,  22 ;  died,  9 ;  remaining  at  end  of  the 
year,  126.  Since  April  ist,  1844,  there  have  been  admitted  641  pa- 
tients between  20  and  25  years  of  age,  647  patients  between  25  and 
30  years  of  age,  650  patients  between  30  and  35  years  of  age,  603 
patients  between  35  and  40  years  of  age,  553  patients  between  40 
and  45  years  of  age,  and  434  patients  between  45  and  50  years  of  age. 
"  From  this  period  of  life,"  says  Dr.  Stearns,  "  the  number  rapidly 
diminish,  and  there  have  been  only  150  persons  admitted  during  the 
whole  thirty-eight  years  who  were  known  to  be  over  seventy  years 
of  age  ;  and  only  316  below  twenty.  It  thus  appears,  so  far  as  these 
statistics  of  the  Retreat  are  evidence,  that  there  exists  a  considerably 
uniform  average  as  to  the  ages  of  persons  who  become  insane  from 
twenty  up  to  forty  or  fifty  years,  and  that  a  larger  number  are  affect- 
ed between  twenty  and  forty,  and  also  during  any  number  of  these 
years  than  there  are  during  any  equal  number  at  other  periods  of 
life.  It  will  be  observed  that  these  are  the  periods  during  which  the 
brain  comes  into  its  largest  activity  and  responsibility.  The  indi- 
vidual no  longer  enjoys  the  support  and  protection  of  the  parental 
home ;  his  relations  to  society  and  the  public  then  become  more  fully 
declared,  and  his  business  cares  and  anxieties  greater ;  besides  there 


i 


TREATMENT    OF    INSANITY.  20/ 

exists  a  larger  measure  of  uncertainty  as  to  success  and  failure  in  all 
the  avocations  and  employments  of  life  than  is  the  case  either  earlier 
or  later.  It  is  during  this  period  that  such  habits  and  customs  of  life 
as  are  unfavorable  to  the  continuance  of  mental  integrity  are  usually 
formed  and  more  fully  take  possession  of  the  individual,  especially 
in  relation  to  the  passions  and  the  use  of  alcohol  and  tobacco.  More- 
over, it  is  at  this  time  that  failures  in  business,  disappointments  in 
relation  to  plans  and  purposes,  and  anxieties  in  relation  to  children 
and  the  support  of  families  are  generally  greater  than  at  other  periods. 
Especially  is  this  the  case  with  those  classes  (already  large  in  this 
country,  and  yearly  becoming  larger)  which  have  never  thoroughly 
learned  any  trade  or  employment,  and  are  obliged  to  depend  on  doing 
so  while  employed  for  wages.  Such  conditions  of  life  and  experi- 
ences, together  with  a  larger  measure  of  brain-susceptibility  and  ac- 
tivity than  exists  later  in  life,  are  some  of  the  causes  why  insanity 
affects  a  larger  number  of  persons  between  twenty  and  forty  than  be- 
tween forty  and  sixty  years  of  age.  After  forty  the  brain  is  less  sensi- 
tive to  external  influences  and  occupations;  the  relations  of  the  indi- 
vidual to  society  and  occupations  are  generally  settled,  and  he  is 
much  less  liable  to  be  affected  by  failure  or  success  in  the  pursuits 
of  life  than  he  is  at  a  younger  age." 

Dr.  Stearns  further  says:  "In  my  report  for  1876,  I  presented 
some  statistics  from  the  history  of  recoveries  in  the  Retreat  since  its 
opening  to  the  year  1875,  and  showed  that  there  had  been  a  some- 
what uniform  diminution  in  the  percentage  of  recoveries  up  to  that 
time,  and  reiterated  a  previously-expressed  opinion  that  the  nature 
of  the  causes  of  insanity  were  becoming  somewhat  changed  or  in- 
tensified, so  that  insanity  is  less  curable  than  it  was  during  the  early 
history  of  the  Retreat.  Since  that  time  the  whole  subject  of  the 
curability  of  insanity  has  been  treated  in  a  very  thorough  manner 
by  Dr.  Pliny  Earle  in  several  of  his  yearly  reports,  and  the  conclu- 
sions at  which  he  arrives  tend  strongly  to  confirm  the  opinion  then 
advanced." 

Statistics  of  the  McLean  Asyhmt  for  the  Insane,  Somerville,  Mass., 
Department  of  Massachusetts  General  Hospital. — The  sixty-fifth  an- 
nual report  of  this  institution,  for  which  we  are  indebted  to  Dr.  Ed- 
ward Cowles,  the  medical  superintendent,  shows :  that  there  were  in 
this  asylum,  January  1st,  1882,  155  patients, — 63  men  and  92  females. 
The  admissions  for  1882  were  82  in  number.  The  whole  number  of 
cases  within  the  year,  237  ;  discharged  recovered,  26 ;  much  improved, 


208  PSYCHOLOGICAL   MEDICINE. 

7;  improved,  14;  unimproved,  15;  deaths,  8;  patients  remaining 
December  31st,  1882,  167.  During  the  year  no  person  was  twice 
admitted.  The  average  duration,  from  the  beginning  of  attack,  of 
all  persons  recovered  was  10.54  months,  and  the  average  duration  of 
their  hospital  residence  was  8.86  months.  The  percentage  of  recov- 
eries on  admissions  was  30.48.  The  number  of  recoveries  was  larger 
by  five  than  in  any  year  since  1870.  Dr.  Cowles  has  some  excellent 
remarks  respecting  the  care  of  the  insane,  which  we  insert  as  follows: 

There  has,  of  late,  been  much  discussion  of  the  question  of  the  curability  of  insanity; 
and  the  results  of  the  treatment  of  the  insane  in  large  and  well-managed  hospitals,  like 
those  in  Massachusetts,  are  still  disappointing  as  compared  with  results  reported  to  be 
gained  in  the  early  days  of  the  older  and  smaller  hospitals.  A  reduction  from  75  per 
cent,  to  20  per  cent,  of  recoveries  is  perhaps  due  to  something  more  than  the  errors  of 
the  older  statistics.  It  is  probably  true  that  the  majority  of  the  insane  can  be  best  and 
most  practicably  treated  away  from  their  homes  and  in  hospitals,  and  these  are  not  yet 
accomplishing  what  has  been  hoped  of  them  in  curative  results.  Instead,  however,  of 
treating  this  fact  in  terms  of  reproach,  it  should  not  be  forgotten  that  mental  disease  in- 
volves the  disorder  of  an  organ  of  a  highly  complex  and  delicate  structure,  and  compar- 
isons between  its  diseases  and  those  of  other  organs  of  the  body  should  not  be  drawn  un- 
fairly. It  has  its  own  physiological  and  pathological  laws ;  and,  at  the  best,  its  diseases 
may  have  to  be  regarded  as  largely  incurable.  The  fact  that  the  insane  are  treated 
mostly  in  hospitals  and  become  burdens  upon  the  State  gives  them  prominence,  because 
of  their  economic  relations.  Let  us  suppose  that  tubercular  diseases  are  to  be  regarded 
as  infectious,  and  their  subjects  are  to  be  put  into  hospitals.  What  public  alarm  would 
be  aroused  by  the  great  number  and  fatality  of  cases  of  this  disease,  now  unrealized,  or 
by  the  burden  of  the  care  of  its  chronic  forms ;  and  how  soon  would  it  become  the  fashion 
to  reproach  those  who  treat  it  because  of  its  incurability  ? 

The  insane  must  be  cared  for  with  due  regard  to  public  and  private  economy,  and  the 
system  now  common  to  all  civilized  countries  of  collecting  them  in  large  hospitals  is 
held  to  be  on  trial.  It  is,  at  all  events,  imperative  that  no  possible  effort  should  be  spared 
to  get  curative  results  from  the  treatment  of  the  insane.  Curability  certainly  diminishes 
with  duration  of  mental  disease,  and  its  earliest  stages  should  be  most  thoroughly  studied 
and  treated.  The  smaller  hospitals  are  endowed  with  greater  facilities  for  individualizing 
cases,  and  for  treatment ;  and,  therefore,  a  great  responsibility  lies  with  them  for  making 
the  best  use  of  those  facilities.  They  should  encourage  the  admission  of  acute  cases, 
and  devote  their  best  energies  to  their  study  and  care.  It  seems  to  me  that  in  such  hos- 
pitals, where  the  means  and  the  opportunity  are  liberally  given,  while  due  regard  is  to  be 
had  to  a  proper  conservatism,  it  is  a  special  duty  to  explore  new  paths,  if  any  there  be, 
beyond  the  beaten  ways  of  procedure  in  the  management  of  the  insane.  To  stand  still 
is  to  fail,  when  progress  is  demanded  and  is  possible;  for  even  negative  results  are  val- 
uable. It  is  also  a  duty  to  report  experiments  for  the  later  tests  of  criticism  and  experi- 
ence, and  hence  this  may  be  deemed  a  fitting  time  and  place  for  putting  on  record  some 
of  the  results  of  the  study  of  the  problems  of  hospital  management  in  this  asylum  during 
the  past  three  years. 

Developing  a  homelike  aspect  of  the  hospital,  destroying  the  suggestion  of  insanity  as 
differing  from  other  diseases,  individualizing  the  patients,  and  perfecting  the  conditions 
for   moral  treatment  are  of  prime  importance.     The  truth  goes  further,  and  includes 


TREATMENT   OF   INSANITY.  2O9 

the  essential  fact  that  we  are  treating  sick  people,  and  are,  after  all,  dealing  with  a 
hospital. 

One  of  the  first  considerations,  therefore,  was  the  quality  of  the  nursing  of  the  sick. 
The  aim  has  been  to  introduce  the  best  methods  of  the  general  hospitals,  by  promoting 
the  growth  of  the  spirit  that  prompts  devotion  to  the  sick;  requiring  constant  personal 
attention  to  them  as  individuals,  by  companionship  as  well  as  nursing ;  introducing 
ward-maids  to  perform  duties  that  distract  the  attention  of  nurses  from  more  important 
ones  ;  increasing  the  number  of  nurses  on  duty  at  night,  so  that  most  of  the  patients  can 
have  the  doors  of  their  rooms  unlocked,  and  all  noteworthy  events  can  be  observed  and 
systematically  reported;  employing  experienced  night  supervisors  to  see  that  all  medical 
directions  are  properly  carried  out,  and  that  everything  is  done  to  promote  the  com- 
fort and  cure  of  the  sick  ;  in  short,  by  providing  a  service  qualified  for  the  task  of  treat- 
ing a  houseful  of  acute  cases.  This  is  the  beginning  of  what  it  is  believed  can  be  accom- 
plished as  the  result  of  the  recent  employment  of  a  superintendent  of  nurses,  and  of  a 
systematic  course  of  training  and  instruction  which  is  to  be  adopted  for  them.  To  one 
who  has  employed  in  hospital  wards  intelligent  and  well-trained  nurses  who  have  an 
interest  in  their  work  as  a  profession,  their  value  in  the  companionship  as  well  as  the 
care  and  treatment  of  the  insane  needs  no  commendation. 

In  the  direction  of  developing  the  hospital  element  of  the  work,  the  employment  of  an 
ample  medical  staff  has  given  increased  satisfaction  during  the  past  year.  An  assistant 
physician  for  each  service,  male  and  female,  is  a  liberal  allowance  for  a  total  of  one  hun- 
dred and  seventy  patients ;  but,  in  an  asylum  of  this  kind,  much  attention  must,  or  can 
well  be  bestowed  upon  individuals.  The  continued  employment  of  a  house-pupil  for 
each  service,  to  do  the  work  of  clinical  clerks,  as  in  general  hospitals,  is  a  valuable  ad- 
dition to  the  organization.  It  is  understood  that  the  time  thus  gained  by  the  assistant 
physicians  from  clerical  and  other  duty  shall  be  employed  in  professional  work.  And, 
to  facilitate  this,  a  room  has  been  fitted  up  fora  laboratory  and  the  use  of  the  microscope; 
and  a  systematic  course  of  study,  begun  a  year  ago,  is  now  going  on  under  the  direction  of 
Dr.  Gannett,  of  Boston,  who  is  also  employed  as  the  pathologist  of  the  asylum. 

Aloral  Treatment. — A  consideration  of  the  moral  treatment  of  insanity  of  course  leads 
over  ground  that  is  not  new,  but  it  may  be  permitted  to  restate  a  few  propositions.  It  is 
important,  at  the  outset,  to  establish  the  principle  which  shall  serve  as  a  basis  for  the 
moral  treatment  of  the  insane  person  as  an  individual.  The  underlying  principle  in  the 
whole  matter  is,  that  the  patient  should  be  treated  as  a  reasoning  being.  In  other  words, 
from  the  moment  he  enters  the  hospital,  it  should  be  assumed  that  he  will  understand 
more  or  less  correctly  all  that  is  said  or  done  to  him.  Therefore,  he  should  be  treated  as 
if  he  were  expected  to  act  rationally,  and  led  to  see  that,  after  his  failure  to  do  what  is 
expected  of  him,  he  brings  upon  himself  friendly  advice,  criticism,  reproof,  and,  if  need 
be,  restriction.  On  the  part  of  others,  while  the  attitude  toward  him  of  physicians  and 
nurses  should  be  as  toward  a  rational  man,  the  fact  of  his  illness  and  mental  obscura- 
tion should  be  kept  in  view  ;  and  the  conditions  of  his  daily  life  should  be  made  easy  by 
conforming  them  as  nearly  as  possible  to  those  of  his  ordinary  experience.  His  clouded 
and  perverted  understanding  should  be  given  as  few  unaccustomed  problems  for  compre- 
hension as  possible  in  his  new  mode  of  life  in  the  hospital. 

The  physiological  basis  of  all  moral  treatment  of  the  insane  is  the  fact  that  the  normal 
functions  of  the  cerebral  organ  may  be  only  temporarily  disturbed  or  only  partially  im- 
paired, whether  by  temporary  disorder  or  pathological  change,  and  the  consequent  fact 
that  in  most  cases  some  degree  of  normal  function  remains.  This  principle  cannot  be 
better  stated  than  by  Dr.  Gairdner,  in  his  presidential  address  to  the  British  Medico-Psy- 
chological Association  last  August.     'Speaking  of  the  improved  treatment  of  the  insape, 

14 


2IO  PSYCHOLOGICAL   MEDICINE. 

begun  in  the  time  of  Pinel  and  Tuke,  he  says  it  has  gradually  come  to  be  regarded  as 
the  truth  that  "the  unsound  mind,  like  the  unsound  body,  can  only  be  regarded  as  an 
instance  of  disordered  function ;  and  that,  however  great  the  disorder,  the  functions  are 
still  there,  and  may  be  roused  into  more  or- less  healthy  activity  by  exactly  the  same  phys- 
iological stimuli  as  are  available  in  the  state  of  health."  He  would  name  as  the  most 
important  gain  of  modern  physiology  and  pathology  for  the  healing  art,  the  modern  con- 
ception or  theory  of  disease, — that  "  disease  is,  for  the  most  part,  normal  function  acting 
under  abnormal  conditions."  He  argues,  therefore,  that  the  insane  mind  is  not  aliena 
metis, hut  has  like  passions- and  emotions  with  the  sound  mind;  and  that  the  sound  ele- 
ments still  remaining  must  be  carefully  respected,  strengthened,  and  built  up  again,  if 
possible. 

All  moral  treatment,  then,  should  be  addresssd  to  the  purpose  of  calling  into  normal 
exercise  the  rational  part  of  the  disordered  mind.  The  patient  should  be  assumed  to  be 
capable  of  some  degree  of  understanding  of  the  fact  that  he  is  ill;  and  all  the  conduct 
of  others  towards  him  should  frankly  and  consistently  declare  this,  before  as  well  as  after 
his  entering  the  hospital.  The  fact  should  be  made  as  plain  as  possible  to  him  that  his 
commitment  by  the  court  is  according  to  law,  and  based  upon  medical  opinion  outside  of 
the  hospital.  There  are  few  patients  who  cannaot  be  beneficially  impressed  in  this  way, 
however  much  they  may  contest  the  correctness  of  the  judgment  upon  them. 

Once  within  the  hospital,  the  conduct  of  physicians  and  nurses  toward  the  patient  should 
show  that  he  is  regarded  as  simply  ill,  and  as  having  no  reason  for  being  ashamed  of  his 
illness.  Therefore,  he  should  always  be  called  a  "  patient,"  and  not  a  "  boarder,"  as  is 
the  custom  in  some  hospitals,  and  has  been  in  this  one  from  its  earliest  days.  This  latter 
t-erm  implies  an  evasion  of  the  fact  of  illness,  as  if  it  were  a  disgrace,  and  by  a  euphem- 
ism fosters  the  very  feeling  of  which  we  are  trying  to  disabuse  the  patient.  Dr.  Kirk- 
bride  has  pointed  out  the  same  effect  as  inherent  in  the  use  of  the  word  "  asylum  "  for 
"  hospital." 

For  the  same  reason,  the  word  "attendant"  is  unfortunate,  although  it  is  so  much 
better  than  the  older  terra,  "  keeper."  It  would  be  only  the  truth  to  call  them  "  nurses." 
While  everything  should  be  done  to  make  the  place  homelike  and  cheerful,  with  pleasant 
parlors,  books,  pictures,  music,  diversion,  and  occupation  suited  to  the  individual,  the  idea 
of  the  hospital  is  in  it  all,  and  no  attempt  should  be  made  to  ignore  it.  It  should  appear 
rather  that  active  attention  is  being  given  to  the  business  of  curing  the  sick.  "  Attend- 
ants "  may  attend  the  infirm  and  incurable;  but  "nurses"  attend  the  sick,  and  the  ex- 
perience of  I'ecovery  from  illness  is  so  common  that  the  very  idea  of  the  presence  of  a 
nurse  logically  carries  with  it  the  other  idea  that  something  is  being  done  to  promote  re- 
covery, and  that  itself  inspires  hope  and  is  curative.  The  keynote  of  all  that  is  addressed 
to  the  patient  on  this  subject  should  be,  "  You  are  ill ;  you  may  get  well." 

In  practically  working  out  the  general  principle  that  has  been  stated,  it  is  believed 
that  successful  results  have  also  been  gained  in  two  other  experiments  during  the  past 
three  years. 

One  of  these  is  the  employment  of  female  nurses  in  men's  wards,  as  described  in  my 
report  of  last  year.  For  the  majority  of  insane  men  this  is  practicable;  and  every  day's 
experience  with  it  teaches  me  to  prize  more  highly  its  value.  To  put  a  man  accustomed 
to  the  comforts,  or  even  if  no  more  than  to  the  habits,  of  domestic  life,  into  a  restricted 
association  with  men,  would  be  to  him  an  experience  of  which  he  probably  has  had  no 
previous  conception.  Such  a  way  of  living  would  be  unnatural  and  unattractive  to  most 
men,  and  to  the  sick  man,  whose  mind  is  already  disturbed,  a  cause  of  added  discomfort. 
In  such  an  association  of  men  alone  the  inevitable  tendency  is  to  degenerate  in  manner 
of  speech  and  conduct;  and  this  is  true,  both  of  the  patients  and  what  is  very  important, 


TREATMENT    OF    INSANITY.  211 

of  the  men  nurses  also.     There  is  something  lacking  after  all  efforts  to  make  the  wards 
homelike  and  agreeable. 

The  presence  of  female  nurses  in  most  of  the  wards,  and  of  young  women  as  ward- 
maids,  is  as  easily  managed  as  in  the  wards  of  a  general  hospital.  Although  some  of  the 
conditions  differ,  there  is  much  to  prove  the  practicability  of  this  in  ordinary  hospitals,  in 
the  successful  management  of  all  the  men's  wards  of  the  Mount  Hope  Retreat  at  Balti- 
more by  the  Sisters  of  Charity.  The  insane  man  coming  into  such  a  ward  is  restrained 
and  softened,  and  practices  instinctively  a  degree  of  self-control  that  he  would  not  have 
thought  of  ti-ying  to  exercise  in  the  presence  of  men  alone.  His  first  impressions  upon 
entering  the  asylum  are  far  more  agreeable  than  in  the  former  case  and  continue  so.  The 
special  qualifications  of  women  for  the  care  of  the  wards  and  the  sick  are  of  great  value, 
and  the  moral  and  curative  influence  of  their  habitual  presence  in  our  wards  for  men  is 
positive  and  would  not  be  willingly  given  up.  The  good  results  that  have  followed  this 
practice  flow  directly  from  its  influence  in  stimulating  the  exercise  of  the  remaining  sound 
elements  of  the  mind,  and  of  healthy  and  decent  habits  of  thought  and  conduct. 

The  other  experiment,  which  is  believed  to  have  given  some  special  and  good  results, 
is  in  regard  to  the  freedom  of  communication  between  patients  and  their  relatives  or 
friends,  by  visiting  or  correspondence.  It  is  now  two  and  a  half  yeai's  since  my  former 
liberal  practice  grew  into  the  adoption  of  the  present  rule  for  the  following  reasons.  Few 
of  the  insane  have  their  understandings  so  confused  and  clouded  as  not  to  leave  enough 
of  normal  mental  function  to  conceive  of  the  reasonableness  of  removing  a  sick  person  to 
a  hospital.  There  is  often  on  the  part  of  persons  so  removed  a  consciousness  of  the  pro- 
priety of  this  actioia,  even  in  those  who  will  not  confess  it.  Even  in  cases  of  maniacal 
excitement  and  melancholia  with  stupor,  we  may  rely  upon  being  able  to  instil  into  the 
mind  some  degree  of  consciousness  of  the  true  nature  of  the  act  of  removal  to  a  hospital. 
When,  however,  we  come  to  abruptly  separate  the  insane  person  from  all  communication 
with  relatives  and  friends,  we  institute  a  condition  of  things  which  is  the  more  difficult  to 
understand  as  the  patient  is  more  insane.  The  patient  probably  knows  the  usual  fact,  that 
the  distance  is  not  great  from  home  and  friends.  Enforced  separation  and  interdiction 
of  communication  beget  suspicion  of  those  friends,  if  it  has  not  been  entertained  before, 
or  of  the  physicians  of  the  hospital.  It  is  of  the  first  importance  not  to  increase  or  arouse 
this  suspicion,  and  to  convince  the  patient  of  the  desire  to  treat  him  with  generous  fair- 
ness and  indulgence.  Therefore  the  rule  is  that,  from  the  outset,  the  relatives  or  friends 
shall  be  allowed  to  visit  the  patient.  Care  is  taken  to  have  it  understood  by  all  con- 
cerned that  the  physician  will  see  no  objection  to  such  visiting  until  the  patient  shall  give 
cause  for  it. 

This  is  the  rtile  ;  but,  like  all  rules,  it  has  its  exceptions.  The  patient  who  has  an  an- 
tipathy and  delusion  regarding  relatives  might  not  be  allowed  to  receive  visits  for  some 
time  after  the  first  one,  or  even  the  first  might  be  denied ;  but  it  is  remarkable  how  few 
patients  there  are  who  require  this  restriction.  In  this  asylum,  of  one  hundred  and  sixty- 
seven  patients  present,  there  are  only  three  who  do  not  receive  visits  from  relatives  quite 
regularly.  One  man  with  chronic  mania  refuses  to  see  them  because  of  a  violent  antipa- 
thy ;  and  the  relatives  of  the  two  other  men  with  mania  have  to  refrain  from  visiting  on 
their  own  account,  but  visits  are  made  by  friends.  It  has  been  observed  that  if  excite- 
ment attends  the  first  visit,  M'hich  should  be  made  early,  it  is  as  a  rule  no  greater  than 
attended  contact  with  friends  at  the  home  recently  left;  and,  in  fact,  this  visit  is  regarded 
as  a  necessary  part  of  the  process  of  accommodating  the  patient  to  the  new  situation  and 
aids  it.  The  first  visits  often  have  a  remarkable  effect  in  disarming  the  patient  of  fast- 
forming  suspicions  as  to  the  purposes  of  friends,  and  help  to  inspire  him  with  a  salutary 
confidence,  which  aids  in  leading  him  to  accept  sooner  the  role  of  an  invalid.     The 


212  PSYCHOLOGICAL   MEDICINE. 

friends,  and  this  term  is  used  to  include  relatives,  learn  by  these  visits  to  render  valuable 
aid  in  the  management  of  the  case,  and  most  readily  accede  to  the  proposition  that  they 
should  refrain  from  %asiting,  if  it  has  proved  not  to  be  good  for  the  patient. 

This  practice  stands  the  test  of  the  continuance  of  the  visits,  even  though,  as  is  some- 
times the  case,  the  first  ones  are  attended  with  some  degree  of  excitement.  The  visits 
are  almost  invariably  desired  by  the  patient,  who  soon  comes  to  understand,  if  need  be, 
that  they  are  allowed  or  denied  according  to  his  conduct,  and  thus  a  means  is  given  for 
stimulating  self-control.  Sometimes,  the  desire  to  see  friends  can  be  aroused  when  it 
has  been  absent ;  and  a  curative  result  is  gained  by  the  exercise  of  a  normal  function  of 
the  mind  in  the  gratification  of  the  desire. 

In  other  exceptional  cases,  as  of  acute  mania,  or  others  with  mental  confusion  or  stu- 
por, the  seeing  of  friends  may  seem  to  give  negative  results,  and  little  notice  may  be 
taken  of  the  visitors ;  but,  in  these  conditions,  it  is  well  known  that  impressions  may 
still  go  in  upon  the  obscured  perceptions,  when  no  outward  sign  is  given,  and  are  remem- 
bered. 

As  far  as  moral  treatment  goes,  in  these  cases  of  mental  confusion  as  well  as  in  others, 
efforts  calculated  to  arouse  into  activity  the  normal  elements  of  the  mind  are  often  of  in- 
estimable value,  though  no  evidence  of  the  good  impressions  thus  made  appears  till  long 
afterward.  What  more  potent  means  of  arousing  healthy  mental  action  than  is  found  in 
the  exercise  of  the  natural  affections  and  emotions,  and  the  consciousness  of  the  occa- 
sional presence  of  friends  whom  the  patient  has  been  accustomed  to  love  and  trust  ? 

The  fact  that  patients  who  have  been  studiously  separated  from  friends  for  a  long  time 
may  have  had  relapses  from  convalescence  almost  established,  following  wearily  longed- 
for  visits  from  relatives,  is  not  a  conclusive  argument  to  prove  that  the  visits  were  made 
too  soon.  It  is  a  fair  question  whether  the  excess  of  emotion,  naturally  aroused  by  a 
meeting  after  long  separation,  may  not  produce  in  such  cases  a  disaster  which  might  be 
averted  under  the  opposite  plan  of  training  the  patient  from  the  outset  to  receive  calmly 
the  visits,  by  the  deprivation  of  which  he  has  not  been  allowed  to  become  distressed. 

Another  important  consideration  is  that,  when  the  relatives  also  are  wearied  by  long 
separation,  they  are  apt  to  remove  too  soon  a  half-convalescent  patient,  at  first  sight  of 
the  improved  condition,  whereas  by  the  other  plan  they  act  more  understandingly  and 
with  calmer  judgment.  As  a  matter  of  fact,  it  rarely  happens  under  this  practice  that 
too  early  removal  of  convalescents  is  urged. 

In  regard  to  correspondence,  the  rule  is  also  a  most  liberal  one,  as  far  as  the  asylum  is 
concerned.  The  patient  and  friends  are  carefully  informed  at  the  outset  that  no  writings 
of  the  former,  sealed  or  unsealed,  will  be  intercepted  by  the  asylum  authorities,  who  pre- 
fer to  be  relieved  of  that  responsibility.  The  patient  is  told  that  whatever  he  writes  ^^^ll 
be  sent  to  the  persons  who  are  to  be  regarded  as  the  natural  or  legal  guardians,  or  to  other 
proper  persons  agreed  upon.  Most  patients  readily  join  in  this  compact,  if  made  at  the 
outset ;  and  the  attitude  thus  taken  by  the  superintendent  increases  greatly  his  influence 
over  the  patient  in  advising  or  checking  him  in  regard  to  writing.  It  often  happens  that 
what  one  is  free  to  do  he  does  not  care  to  do,  or,  if  he  becomes  dissatisfied  sometimes 
with  the  action  of  friends  in  arresting  letters, — as  of  course  must  be  done  for  the  protec- 
tion of  the  patient  from  consequences  he  would  afterwards  regret, — there  is,  as  a  rule,  a 
good  reason  to  be  given.  At  all  events,  it  is  found  that  dissatisfaction  is  reduced  to  a 
minimum ;  and  it  is  made  clear  that  there  is  no  reason  known,  as  far  as  the  asylum  is  con- 
cerned, why  all  letters  should  not  go  from  it.  It  is  easy  to  gain  through  friends  the  valu- 
able information  concerning  the  state  of  the  patient's  mind  afforded  by  his  letters;  and 
the  friends,  being  taken  into  the  management  of  the  case  throughout,  have  a  better  under- 
standing of  their  duty  to  the  patient  when  his  home  relations  are  resumed. 


TREATMENT    OF    INSANITY.  213 

One  more  important  point  is  that  every  well-behaved  visitor,  if  it  is  desired,  is  allowed 
to  go  to  the  room  of  any  patient  it  is  proper  for  him  to  visit,  with  due  regard  to  the  com- 
fort of  others.  The  nurses  are  trained  to  expect  this  at  any  time,  and  it  is  demonstrated 
to  all  concerned  that  there  are  no  dark  places  in  the  asylum  to  be  concealed. 

In  thus  setting  forth  the  working  of  what  is,  theoretically  and  virtually,  a  removal  of 
restrictions  that  have  been  regarded  as  peculiar  to  hospitals  for  the  insane,  the  aim  is  to 
show  that  this  is  justifiable  as  the  logical  sequence  of  the  carrying  out  of  the  principles 
recited  in  the  beginning  of  this  discussion.  As  a  practical  demonstration  of  the  results 
of  the  effort  being  made  to  put  this  asylum  on  the  basis  of  a  general  hospital,  particularly 
as  to  its  being  an  open  and  accessible  institution,  it  is  shown  by  this  report  that  the  twenty- 
six  recoveries  of  the  last  year  were  possible  under  the  liberal  rule  which  permitted,  from 
the  beginning  of  the  treatment  of  these  cases,  including  various  types  of  acute  mania, 
melancholia,  etc.,  regular  communication  with  relatives  and  friends,  guarded  by  a  careful 
study  of  its  effects  and  its  occasional  limitation. 

It  was  the  influence  of  the  growth  of  the  principles  cited  that  wrought  the  improve- 
ment in  asylum  management  from  the  days  of  Pinel  and  Tuke  to  the  present  time.  It  is 
not  so  many  years  since  it  was  believed  that  there  was  a  special  curative  influence  in  en- 
tire separation  of  the  majority  of  the  insane  from  friends  for  long  periods,  and  in  their 
strict  seclusion  in  asylums.  Not  only  was  rest  in  bed  enforced  by  mechanical  restraint 
to  prevent  exhaustion  in  maniacal  cases,  but  many  appliances  were  employed  to  keep 
quiet  the  restless  sufferers  from  nervous  irritability.  It  has  gradually  come  to  pass  that, 
at  the  present  time,  large  freedom  is  accorded  to  the  insane  ;  and  the  former  practice  of 
seclusion  from  friends  and  interdiction  of  communication  is  greatly  modified,  and  in  some 
instances  reduced  to  small  proportions.  The  practice  is  not  uniform  in  this  regard,  how- 
ever ;  and  there  is  reason  to  believe  that  the  views  held  by  many  alienists  are  but  a  modi- 
fication of  the  former  ones  as  to  the  curative  effect  of  strict  seclusion  in  hospitals,  although 
some  have  gone  so  far  in  this  direction  as  to  practically  abandon  it. 

The  truth  lies  somewhere  between  the  older  view  and  a  modern  one,  in  regard  to  the 
treatment  of  the  insane  at  their  homes.  It  is  believed  that  the  line  may  be  drawn  at  the 
point  of  the  removal  of  the  patient  to  hospital  and  his  separation  from  home  and  the  former 
"moral  and  physical  surroundings,"  and  that  beyond  this  point,  the  accepted  rule  of 
practice  should  be  that  liberal  communication  with  friends  is  to  be  used  as  a  therapeutic 
means. 

Some  evidence  of  a  negative  character  is  available  in  support  of  this  proposition.  It 
appears  not  only  that  the  growing  liberality  of  modern  times- in  this  regard  is  doing  no 
harm  to  the  insane,  but  that  there  is  some  special  evidence  to  show  that  in  the  treatment 
of  melancholia,  which  includes  so  large  a  class  of  cases,  the  methodical  employment  of 
seclusion  and  rest  outside  of  hospitals  for  the  insane  has  actually  failed  to  be  of  benefit. 
While  the  older  views  of  seclusion  and  rest  have  been  undergoing  modification  leading 
to  practical  abandonment  by  some  of  those  who  have  treated  the  insane,  one  of  the  most 
important  contributions  to  the  healing  art  in  modern  times  is  that  made  by  Dr.  Weir 
Mitchell  in  the  well-known  doctrine  of  "  Rest  Treatment "  by  means  of  "  seclusion, 
rest,  massage,  electricity,  and  overfeeding,"  so  successfully  employed'  in  the  treatment  of 
nervous  exhaustion. 

If,  then,  "seclusion"  and  "  rest"  are  of  such  essential  value  in  fehe-  treatment  of  ner- 
vous exhaustion  in  persons  not  insane,  why  are  they  not  also  of  value  in  insanity,  which 
often  is  simply  a  greater  degree  of  the  same  disorder  of  the  nervous  system  ?  The  ans-wer 
is,  possibly,  that  in  the  former  case  the  functions  of  the  reasoning  faculties  are  so  nearly 
in  a  normal  state  as  to  permit  "  seclusion  "  to  be  regarded  and  accepted  by  the  patient  as 
a  reasonable  necessity,,  and  the  path  upward  toward  health  is  from  a  point  where  the 


214  PSYCHOLOGICAL    MEDICINE. 

mind  is  not  controlled  by  delusions  or  given  up  to  despair.  After  the  mental  functions 
are  unbalanced  we  have  to  deal  with  a  new  set  of  conditions,  and  our  efforts  must  be 
more  largely  addressed  to  the  moral  treatment  of  the  disordered  and  weakened  mind. 

In  experiments  with  the  rest  treatment  here,  during  the  past  three  years,  it  has  been 
found  necessary  to  modify  it.  Cases  of  mental  depression  are  apt  to  have  this  increased 
by  rest  in  bed,  and,  to  those  in  which  melancholia  is  accompanied  by  a  state  of  nervous 
irritability  and  constant  uneasiness  or  anguish,  enforced  rest  is  intolerable  and  positively 
harmful.  While  rest  is  useful  in  some  conditions  of  melancholia  and  other  cases,  and 
benefit  has  been  derived  from  massage  by  producing  tissue  waste  and  improving  nutrition, 
and  from  the  other  means  of  treatment,  "  seclusion  "  has  been  almost  entirely  abandoned 
as  not  useful  and  as  depriving  the  patient  of  what  is  beneficial.  Interesting  and  valuable 
evidence  on  this  point  is  generously  afforded  me  by  Dr.  Mitchell,  who  has  given  me  per- 
mission to  quote  from  a  recent  letter  some  statements  which  he  has  never  published.  He 
says  that  in  the  treatment  of  "  not  a  small  number  of  cases  of  melancholia  with  bad  nutri- 
tive breakdown,  in  which  I  attempted  to  relieve  by  rest,  etc.,  I  made  some  successes,  but 
more  failures — made,  in  fact,  so  many  that  I  gave  up  at  last  the  effort  to  treat  in  this  way 
distinct  cases  of  melancholy."  "  I  may  use  massage  or  electricity  in  melancholy,  but  I 
do  not  seclude  or  rest  these  cases." 

The  rest  treatment  has  been  for  some  years  extensively  and  most  successfully  employed 
by  Dr.  W.  S.  Playfair,  in  England.  He  says,  in  the  London  Laiicet,  December,  1881, 
of  the  cases  that  are  likely  to  lead  to  disappointment,  that  one  class  is  of  those  in  which 
there  is  some  definite  mental  disease,  and,  after  a  short  tidal  in  melancholia,  he  felt  bound 
to  relinquish  the  treatment. 

Wliat  is  true  of  "  seclusion '"'  in  the  treatment  of  melancholia  has  also  been  observed 
here  to  be  true  of  other  forms  of  insanity,  and  concurrent  testimony  is  not  lacking  from 
those  who  treat  the  insane  in  hospitals. 

While  there  is  unquestionably  a  growing  liberality  in  the  matter  of  freedom  of  commu- 
nication with  the  insane  in  hospitals,  it  is  to  be  recognized  that  more  will  be  accomplished 
in  this  direction  by  acting  upon  a  correct  theory  and  with  a  clear  purpose.  Instead  of  a 
modification  of  the  old  rule,  its  reversal  is  advocated,  and  the  making  of  limitations  of 
communication  the  exception  to  the  rule. 

The  point  now  desired  to  be  made  is  that  there  is  a  scientific  reason  for  putting  the 
insane  sick  person  upon  the  same  basis,  both  as  to  medical  and  moral  treatment,  as 
the  general  hospital  patient;  and,  in  regarding  him  simply  as  the  subject  of  a  disease 
in  which  normal  function  is  acting  under  abnormal  conditions,  it  is,  therefore,  good 
practice  to  unhesitatingly  foster,  encourage,  and,  if  need  be,  stimulate  the  exercise  of 
all  normal  mental  functions,  being  guided  by  symptoms  as  they  appear  as  to  all  modifi- 
cations of  the  general  principle  in  regard  to  change  of  residence,  restriction  of  liberty, 
and  seclusion,  as  well  as  medical  treatment  proper. 

Statistics  of  the  North  Caroli^ia  Lisane  Asylum,  Dr.  Eugene  Gnssoin, 
Superintendent. — The  annual  report  of  this  institution  for  1882  shows 
that  the  total  number  of  admissions  since  the  opening  of  the  institu- 
tion, in  1856,  amounts  to  1467.  The  total  number  discharged,  for 
the  same  time,  is  11 89.  Of  these,  385  were  discharged  as  cured,  151 
were  improved,  225  unimproved,  and  429  died.  There  are  now 
under  treatment  278  cases.  There  was  a  total  of  334  cases  treated 
during  the  year  1882. 


TREATM.ENT    OF   INSANITY,  "  21$ 

Statistics  from  many  more  asylums  might  be  given,  and  such 
reports  as  I  have  before  me  all  testify  ^o  the  highest  degree  of  con- 
tinuous and  faithful  labor  among  the  insane,  for  their  welfare  and 
cure,  by  the  superintendents  of  the  asylums  in  the  different  States  of 
the  Union,  but  want  of  space  forbids  the  insertion  of  any  more.  To 
all  these  men  is  due  from  the  profession  a  generous  recognition  of 
their  services  in  the  -field  of  psychiatry  and  in  the  cause  of  humanity. 

The  .ratio  of  recovery  in  insanity 'depends  largely  upon  the  charac- 
ter of  the  diseases  and  the  ages  of  persons  received  in  ouc  asylums 
and  hospitals;  also  upon  the  length  of  time  the  disease  has  existed, 
a-nd  upon  the  degree  with  v/hich  it  has  affected  the  system.  Persons 
in  whom  mental  disease  has  existed  for  several  years,  or  who  have 
■experienced  several  attacks,  or  persons  beyond  sixty  years  of  age, 
or,  finally,  those  affected  with  organic  disease  of  the  -nervous  system, 
rarely  recover,  and,  consequently,  when  any  of  these  characters  of 
disease  largely  prevail  the  percentage  of  recoveries  becomes  less. 
There  is  very  little  doubt  that,  in  an  increasing  n-umber  of  cases, 
insanity  is  dependent  upon  organic  changes  in  the  brain  and  spinal 
cord.  If  this  be  so,  it  will  not  tend  either  to  a  diminution  of  the 
number  or  to  an  amelioration  in  the  character  of  the -mental  disor- 
ders of  those  who  are  now  sent  to  our  State  institutions  for  treatment 
There  seems  to  be  a  thorough  ignorance  among  the  general  popula- 
tion of  the  primary  laws  and  conditions  of  mental  health,  and  the 
greater  part  of  the  peof)le  neither  understand  nor  practice  such  hygi- 
enic regulations  as  are  necessary  for  its  preservation.  Educated  men, 
professional  men,  clergymen,  lawyers,  and  physicians  do  not  seem  to 
understand  that  the  laws  of  mental  health  imperatively  demajid  chd^nge 
and  variety,  failing  which,  the  brain  inevitably  succ-umbs.  Our 
women,  too,  need  more  change,  rest,  and  recreation,  especially  those 
who  live  in  the  country  districts,  to  change  the  ceaseless  current  of 
thought,  care,  anxiety,  and  household  work. 

Pinel's  and  Esquirol's  Improvements. — As  Pinel  was  one  of  the  first 
to  properly  recognize  and  classify  insanity,  so,  in  speaking  of  treat- 
ment, we  would  refer  to  him  in  his  humane  endeavors  and  successful 
efforts  to  do  away  with  the  beating  and  cruel  treatment  of  the  insane. 
He  has  elsewhere  aptly  been  termed,  "  The  Father  of  the  Modern 
Treatment  of  Insanity."  His  pupil,  Esquirol,  also,  was  the  most  suc- 
cessful of  his  immediate  successors  in  carrying  out  Pinel's  ideas  in 
treating  insanity  and  in  advancing  the  scientific  knowledge  regarding 
it.     The  treatment  of  insanity  has  improved  up  to  the  present  day, 


2l6  PSYCHOLOGICAL    MEDICINE. 

and  the  success  which  has  been  reached  in  abridging  maniacal  attacks 
and  warding  off  dangerous  excitement  gives  us  a  much  different  class 
of  patients,  both  in  behavior  and  appearance,  than  could  have  been 
found  fifty  years  ago.  This  change,  which  has  taken  place  gradu- 
ally as  the  natural  result  of  improved  modes  of  treatment,  has  not 
been  fully  recognized  by  the  profession  at  large.  Kindness  and 
moral  and  hygienic  treatment  have  achieved  great  triumphs  over  the 
cruel,  harsh,  and  unsympathizing  methods  which  characterized  for- 
mer times.  One  great  rule  to  be  observed  in  the  management  of  the 
insane  is  that  they  are  invariably  to  be  treated  with  kindness  and 
consideration.  Their  peculiarities  should  never  be  lost  sight  of,  but 
should  never  be  made  the  topic  of  conversation  or  ridicule.  In  the 
excited  state  of  the  nervous  system  in  the  insane  a  careless  or  an  un- 
kind word  is  often  deeply  felt,  and  all  efforts  toward  a  cure  may  be 
rendered  futile  by  the  patient  perceiving  in  his  physician  the  want  of 
sympathy  and  kindness  of  heart  which  he,  above  all  others,  has  a 
right  to  expect  and  demand  from  us.  The  insane  are  as  amenable  to 
kindness,  as  a  rule,  as  sane  people,  and  will  almost  invariably  repay 
it  by  good  behavior,  while  the  opposite  course  is  quite  as  sure  to 
counteract  all  our  efforts  in  their  behalf.  As  in  all  other  diseases, 
hygienic  influences  must  be  insisted  on,  and  pure  air,  pleasant  sur- 
roundings, and  good  food  are  of  great  importance.  The  mind,  to  be 
normal,  must  be  associated  with  a  healthy  physical  state,  and  we 
must,,  in  the  treatment  of  the  insane,  attend  primarily  to  these  things, 
aad  not,  by  any  means,  regard  them  as  beneath  our  notice. 

Home  T^-eatinent,  or  Treatment  away  from  Home. — Many  persons 
question  the  propriety  of  confining  a  patient  in  an  asylum,  private  or 
otherwise,  maintaining  that  if  they  can  afford  to  keep  the  patient  at 
home  and  provide  medical  attendance,  and  an  attendant  for  him,  he 
is  much  better  taken  care  of.  This,  with  the  exception  of  a  limited 
class  of  cases  in  the  incipient  stages  of  insanity,  is  a  very  mistaken 
idea,  and  one  very  injurious  to  the  patient  hiiYiself.  One  of  the  most 
marked  characteristics  of  the  insane  man,  is  his  intense  egotism,  if  it 
may  be  so  called ;  or  more  properly  speaking,  it  consists,  in  the  lan- 
guage of  Dr.  Blandford,  in  an  "  extreme  concentration  of  the  whole 
thought  and  ideas  on  self  and  on  all  that  concerns  self"  At  home 
he  is  more  or  less  the  master  of  the  house,  and  regards  himself,  when 
restrained,  as  a  deeply  injured  man,  and  chafes  much  more,  and  is 
more  truly  a  prisoner  in  his  own  home  than  when  allowed  the  com- 


TREATMENT    OF    INSANITY.  21/ 

parative  liberty  of  a  well-regulated  private  or  public  hospital  for  the 
insane. 

When  in  such  a  hospital  he  loses  or  merges  his  identity  more  or 
less  with  his  companions,  which  is  an  excellent  thing  for  him,  as  he 
ceases  to  be  the  centre  of  observation  and  remark,  and  is  treated  and 
noticed  precisely  in  the  same  way  as  are  the  thirty  or  forty  other  pa- 
tients who  are  his  companions.  A  very  striking  instance  of  this 
kind  occurred  in  a  patient  of  good  education,  who,  upon  becoming 
insane,  imagined  himself  the  Supreme  Being,  and  insisted  upon  ex- 
ercising all  the  fancied  prerogatives  of  such  a  being. 

He  became  very  troublesome  and  dangerous  to  those  about  him, 
and  was  entirely  absorbed  in  the  contemplation  of  his  own  greatness, 
which  idea  was  fostered  by  the  attention  he  received,  and  the  pri- 
vate room  in  the  asylum  of  which  he  was  an  inmate.  He  was  ac- 
cordingly removed  from  his  room  to  a  ward  in  the  asylum  contain- 
ing twenty  or  thirty  other  patients,  and  was  given  to  understand  that 
the  amount  of  his  liberty  and  the  privileges  which  he  enjoyed  would 
depend  entirely  upon  his  behavior.  He  at  once  perceived  and  at 
first  angrily  remonstrated  against  the  want  of  attention  paid  to  his 
whims  and  caprices,  but  soon  understood  that  he  was  not  regarded 
by  the  attendants  as  in  any  way  superior  to  the  other  patients,  and 
in  their  treatment  of  him  was  manifested  no  attention  at  all  to  his 
delusion.  Finding  his  endeavors  to  exercise  his  authority  fruitless, 
he  gave  up  his  imperious  and  unrestrained  demeanor,  and  soon  sub- 
mitted quietly  to  the  order  and  discipline  of  the  institution,  and  was 
afterwards  one  of  the  best-behaved  patients  in  the  ward,  rarely  re- 
curring to  his  delusion. 

Moral  Treatment. — Regarding  the  moral  treatment  of  the  insane, 
the  physician's  attributes  have  been  well  defined  by  Drs.  Bucknill 
and  Tuke  as  follows :  "  The  physician  who  aims  at  success  in  the 
moral  treatment  of  the  insane,  must  be  ready  '  to  be  all  things  to  all 
men,  if  by  any  means  he  might  save  some.'  He  must,  nevertheless, 
have  a  good  backbone  to  his  character,  a  strong  will  of  his  own, 
and  with  all  his  inflections  be  able  to  adhere  with  singleness  of  pur- 
pose and  tenacious  veracity  to  the  opinions  he  has  on  sound  and 
sufficient  reasons  formed  of  his  patient,  and  the  treatment  needed  to 
be  pursued  towards  him.  With  self-reliance  for  a  foundation  to  his 
character,  it  requires  widely  different  manifestations  to  repress  ex- 
citement, to  stimulate  inertia,  to  direct  the  erring,  to  support  the 
weak,  to  supplant  every  variety  of  erroneous  impression,  to  resist 


2l8  PSYCHOLOGICAL  MEDICINE. 

ever}'-  kind  of  perverted  feeling,  and  to  check  every  form  of  pernicious 
conduct." 

Clinical  Instruction  in  Hospitals. — In  connection  with  the  subject 
of  the  treatment  of  mental  disorders,  I  think  there  is  a  much  needed 
reform,  which,  if  carried  out,  would  make  mental  disorders  far 
better  understood  by  the  medical  profession  generally  than  they 
are  to-day.  The  trustees  and  managers  of  our  lunatic  hospitals  are 
too  often  opposed  to  reforms,  and  wish  no  changes  or  improvements ; 
but  I  think  the  change  I  propose  is  due  both  to  the  general 
medical  profession  and  to  the  public  who  support  them,  so  that  the 
general  practitioner  may  be  so  educated  that  he  may  recognize  the 
first  symptoms  of  insanity,  and  be  able  to  cure  it  in  its  incipient 
stages,  without  perhaps  having  recourse  to  a  State  hospital  for 
the  insane  at  all.  I  refer  to  a  proper  provision,  which  ought  to 
be  made  in  every  public  hospital  for  the  insane,  for  both  clinical 
and  pathological  instruction,  by  lectures  by  the  physician  in  chief 
and  others,  to  diffuse  a  thorough  knowledge  of  the  disease  and 
its  treatment  throughout  the  medical  profession.  With  such 
knowledge  as  could  easily  be  acquired  in  this  way,  physicians 
could  probably  cure  many  patients  in  the  early  stages  of  the  disease, 
so  that  it  would  be  unnecessary  to  send  them  to  a  hospital  at  all. 
Insanity  is  much  more  important  than  many  diseases  which  receive 
very  careful  study  in  our  medical  schools,  and  I  think  it  of  equal 
importance  at  least  that  this  class  of  cases  should  receive  a  due 
amount  of  study.  It  is  a  great  mistake  to  erect  such  large  and  ex- 
pensive buildings,  costing  three  or  four  thousand  dollars  for  each  pa- 
tient; making  efficient  administration  very  difficult;  abuses  more 
likely  to  occur;  aggregating  great  masses  of  mentally  diseased  per- 
sons, so  that  both  the  per  cent,  of  cures  is  less  and  the  rate  of  mor- 
tality greater  than  in  smaller  hospitals ;  making  good  ventilation 
next  to  impossible,  and  also  rendering  efficient  drainage  and  sew- 
erage very  difficult ;  and  making  daily  remedial  exercise  in  the  open 
air  for  all  the  inmates,  when  possible — a  most  important  therapeutic 
measure — very  difficult  indeed.  We  should  have  smaller  hospitals 
and  more  of  them,  and  the  insane  would  then  have  more  employment, 
more  liberty, — and,  in  my  opinion,  a  better  chance  of  cure  than  when 
confined  in  an  overcrowded  hospital. 

Food,  Aimisenie7it,  Work,  etc. — In  treating  the  insane,  the  great  ne- 
cessity is  for  better  food,  more  amusements,  which  draw  off  the  mind 
from  the  delusions  which  occupy  it,  and  combat  depression  of  mind 


TREATMENT    OF    INSANITY.  2I9 

by  bringing  before  it  new  scenes  and  objects,  and  lastly,  more  free- 
dom and  liberty  and  less  mechanical  restraint.  We  have  improved 
the  condition  of  the  insane  materially  during  the  past  few  years,  and 
have  rendered  a  residence  in  an  asylum  less  irksome  and  more  bene- 
ficial for  those  who  are  obliged  to  resort  to  such  institutions.  We 
have  abolished  mechanical  restraint,  except  in  rare  instances  where 
it  is  necessary  for  the  patients'  safety  or  of  those  about  them ;  have 
abolished  all  forms  of  punishments,  and  have  improved  the  quality 
of  food  and  clothing.  The  insane  should  be  encouraged  to  go  out- 
side of  the  walls  of  the  institution  of  which  they  are  inmates,  as  far 
as  is  practicable,  for  work  or  pleasure,  when  their  behavior  justifies 
this  measure.  In  this  way  they  are  put  on  their  honor  and  good  be- 
havior, and  where  one  may  occasionally  escape,  doing  but  little  in- 
jury, thousands  will  be  essentially  benefited,  and,  in  some  cases,  cured 
for  life.  The  physician  should  ascertain  what  bodily  and  intellectual 
exercises  have  been  pursued  by  his  patient  in  early  life,  and  should 
endeavor,  by  proper  appliances,  to  bring  these  external  causes  to  bear 
appropriately  upon  each  particular  case.  Attempts  may  also  be  made 
to  restore  the  healthy  function  of  mind  by  recommending  such  lite- 
rary studies  and  accomplishments  as  have  been  known  to  previously 
interest  and  amuse  the  patient.  The  treatment  must  be  of  a  varied 
character  to  meet  the  requirements  of  each  case  at  different  periods. 
We  must  remove  the  disease,  build  up  the  health,  draw  off  the  mind 
from  morbid  fancies,  and  lead  our  patients  to  brighter  and  more 
healthy  views  of  life  and  its  surroundings.  We  must  combat  dis- 
eased actions,  produce  sleep,  and  strengthen  the  whole  system.  We 
must  lead  our  patient  to  a  careful,  regular,  and  more  healthy  course 
of  life. 

In  insanity  we  have  an  abnormal  state  of  nervous  tension  and  pent- 
up  nerve-force,  which  must  expend  itself  in  some  direction,  and  must 
generate  an  equivalent  manifestation  of  force,  either  m  feeling,  thought, 
or  bodily  action.  If,  then,  we  cause  the  nervous  excitement  or  pent-up 
nerve-force  to  be  expended  in  bodily  or  muscular  action  by  means 
of  employment,  we  shall  decrease  correspondingly  the  morbid 
thoughts  and  feelings  which  are  caused  by  the  intensity  of  the  cere- 
bral excitement.  If  we  allow  our  patients  to  remain  idle,  the  whole 
pent-up  nerve-force  is  expended  and  concentrated  upon  thoiiglit  and 
feeling,  which  become  morbidly  intensified  and  perverted,  and  at  last 
produce  incurable  and  organic  changes  in  the  brain,  which  might 
have  been  arrested  by  drawing  off  the  nerve-force  in  the  channels  of 


220  PSYCHOLOGICAL   MEDICINE. 

labor  and  employment,  and  giving  a  new  direction  to  the  thoughts 
and  feelings.  Out-of-door  work  is  very  valuable  for  patients  in  pro- 
moting assimilation  and  digestion,  and  strengthening  the  muscular 
system,  and  should  be  employed  whenever  practicable.  Light  work 
gives  the  patient  something  to  think  about,  and  occupies  his  mind  in 
a  healthful  manner,  while  being  shut  up  constantly  indoors  tends  to 
enfeeble  the  body,  and  the  mind  is  occupied  too  often  in  revolving 
the  delusions  which  it  should  be  the  aim  of  the  physician  to  banish 
as  far  as  possible.  As  it  is  impossible  for  the  majority  of  patients  to 
be  employed  in  this  manner,  it  is  desirable  to  find  some  light  em- 
ployment indoors.  While  it  is  comparatively  easy  to  find  employ- 
ment for  women,  such  as  sewing,  knitting,  washing,  and  making 
dresses,  the  men  are  not  so  favorably  situated,  as  the  expense  of  fit- 
ting up  workshops  is  so  great  that  in  most  instances  it  is  not  con- 
sidered a  sufficiently  valuable  adjunct  to  justify  the  necessary  outlay. 
They  may  be  taught,  however,  to  do  light  work,  such  as  cane-seating 
chairs,  etc.,  and  in  such  ways  occupy  their  minds  and  afford  them 
some  muscular  exercise,  however  slight.  The  foreign  asylums  have 
systematized  manual  labor  to  a  much  greater  extent  than  in  this 
country;  and  some  of  them,  as  the  Asylum  of  Ouatre  Mares,  near 
Rouen,  do  a  great  deal  of  work  in  all  the  trades.  There  was,  a 
short  time  ago,  an  interesting  exhibition  for  the  public  in  the  lunatic 
asylum  at  Briinnfeld,  near  Vienna.  The  objects  exhibited  were  di- 
vided into  three  classes,  the  first  comprising  215  articles  made  en- 
tirely by  the  patients  ;  the  second,  articles  destroyed  by  them  in  their 
maniacal  excitement ;  and  the  third,  models,  etc.,  showing  how  they 
are  lodged  and  clothed.  Among  the  articles  in  the  first  class  are 
delicately-carved  meerschaum  pipes,  lace,  picture-frames,  and  a  re- 
markable collection  of  paintings  by  Kratky,  who,  before  he  became 
insane,  was  a  celebrated  artist  at  Vienna.  These  paintings  show  no 
sign  of  his  insanity,  and  one  of  them  was  a  wonderfully  life-like 
representation  of  the  insane  hearing  mass  in  the  chapel  attached 
to  the  asylum.  Next  to  these  specimens  of  the  constructive  skill 
of  the  inmates  are  placed  huge  iron  bars  bent  double,  spoons  and 
iron  plates  broken  to  pieces,  and  doors  split  in  half.  The  favorite 
occupation  was  writing  and  drawing,  in  which  some  of  them  had 
become  very  proficient.  Recreation  is  also  more  indulged  in 
abroad  than  in  our  asylums.  At  the  Fisherton  Asylum,  near 
Salisbury,  England,  which  is  a  private  institution,  accommodating 
about  six  hundred  patients,  a  separate  brick  building  was  erected  for 


TREATMENT   OF   INSANITY.  221 

the  purposes  of  recreation.  It  is  one  hundred  feet  in  length  by- 
thirty  in  width.  At  one  end  of  the  interior  of  this  building  is  a 
stage,  fitted  up  with  all  the  accessories  for  private  theatricals.  At 
the  Prestwick  Asylum,  near  Manchester,  is  a  very  large  and  hand- 
somely-painted room,  which  is  devoted  to  music  and  theatricals.  At 
the  lunatic  asylum  at  Ghent,  the  Hospice  de  Guislain,  are  four  hun- 
dred and  seventy  male  patients,  who  are  variously  employed  in  shoe- 
making,  bookbinding,  combing  flax,  making  twine,  weaving  cloth, 
and  in  carpenter-work  and  work  out  of  doors.  There  are  also  rooms 
for  music  and  smoking.  At  the  asylum  at  Clarendon,  near  Paris, 
are  six  hundred  patients  of  the  paying  class,  for  whose  amusement 
are  provided  a  library  and  billiard  room.  The  best  of  our  ov/n  asy- 
lums afford,  however,  as  good  facilities  for  amusements  as  the  foreign 
ones,  if  not  on  so  extended  a  scale,  while  the  condition  of  the  pa- 
tients and  their  care  and  treatment  are,  as  a  general  rule,  superior  to 
those  of  the  foreign  asylums.  There  is  a  very  interesting  colony  of 
about  thirteen  hundred  lunatics  at  Gheel,  in  Belgium,  which,  in  185 1, 
was  placed  under  governmental  control.  The  following  interesting 
description  of  it  is  from  the  Brussels  correspondent  of  the  Pall  Mall 
Gazette : 

Yesterday  an  excursion  to  the  lunatics'  colony  at  Gheel  was  undertaken  by  about  forty 
members  of  the  International  Medical  Congress.  Gheel  is  situated  in  the  province  of 
Antwerp,  and  in  that  portion  of  Belgium  known  as  the  Campine,  a  flat  country,  with  fine 
bracing  air.  We  started  early  in  the  morning  for  Herenthals,  which  by  railway  is  at  a 
distance  of  two  hours  and  forty  minutes  from  Brussels.  From  Herenthals  a  drive  of  one 
hour  and  forty  mmutes  by  car  took  us  to  Gheel.  Near  a  country  inn,  at  about  a  league 
distance  from  Gheel,  we  were  already  met  by  one  of  the  lunatics.  Dr.  Bulckens,  the 
director  of  the  Gheel  colony,  under  whose  guidance  the  excursion  was  made,  presented 
him  to  us.  He  answered  very  intelligently  all  the  questions  put  to  him.  He  had  been 
a  schoolmaster,  and  was  now  giving  private  lessons  in  French,  Latin,  and  other  subjects 
in  the  farmers'  houses  of  the  neighborhood.  He  begged  not  to  be  detained  long,  as  his 
pupils  were  waiting  for  him.  The  poor  schoolmaster's  madness  was  of  a  religious  kind. 
He  told  us  that  he  was  quite  happy,  and  did  not  wish  ever  to  leave.  On  arriving  at  Gheel 
we  were  received  at  the  asylum — a  fine  red-brick  building,  surrounded  with  nice  planta- 
tions— by  Dr.  Peters,  the  assistant  of  the  director.  In  the  committee-room  Mile.  Bulck- 
ens, the  director's  daughter,  invited  us  to  take  the  usual  Belgian  morning  refreshment 
— Madeira  and  cakes;  and  then  Dr.  Bulckens  gave  explanations  concerning  the  colony. 
It  is  of  very  ancient  origin  :  a  legend  places  it  as  far  back  as  the  seventh  century,  attribut- 
ing it  to  Sainte  Dymphne  (Dymphna  or  Digna),  the  daughter  of  an  Irish  king,  who  came 
to  live  at  Gheel,  where  she  also  underwent  martyrdom,  and  became  then  the  protectress 
of  the  insane.  However,  it  is  proved  that  as  early  as  the  twelfth  century  foreign  lunatics 
were  sent  to  Gheel,  for  the  sake  of  the  special  treatment  given  there.  This  treatment 
differs  from  that  in  use  everywhere  else.  The  lunatics  are  not  kept  in  an  asylum,  but 
hoard  and  lodge  with  the  inhabitants.     In  1851  the  institution  was  reorganized  and  placed 


222  PSYCHOLOGICAL   MEDICINE. 

under  the  government.  Since  then  a  great  increase  has  taken  place  in  the  number  of  pa- 
tients sent  there.  The  commune  of  Gheel,  with  its  outlying  hamlets,  is  very  extensive. 
It  covers  i  i,ooo  hectares,  and  the  number  of  inhabitants  is  also  about  i  i,ooo.  The  luna- 
tics number  now  about  1300  of  both  sexes.  The  commune  is  divided  into  four  sections. 
At  the  head  of  each  is  placed  a  medical  man  and  an  overseer.  The  patients  are  froon 
all  nations  and  all  ranks  of  society,  and  they  receive  accommodation  according  to  their 
means.  The  wealthy  are  placed  with  the  wealthier  class  of  inhabitants,  and  the  poor 
with  the  poorer.  The  pauper  lunatics,  for  whose  support  their  respective  communes  have 
to  pay,  belong  to  the  last  category.  The  more  dangerous  class  of  lunatics  are  placed 
in  the  outlying  isolated  hamlets.  They  are  divided  into  sections  according  to  the  na- 
ture of  their  disease,  and  the  Walloon  patients  are  kept  in  two  separate  hamlets  (Gheel  is 
a  purely  Flemish  place,  but  most  people  understand  French),  so  as  to  be  companions  to 
one  another.  The  11,000  inhabitants  are,  so  to  speak,  all  engaged  in  the  surveillance  of 
the  patients,  which  makes  about  nine  overseers  for  every  patient.  The  surveillance,  not 
being  perceived  by  the  patients,  of  course  does  not  irritate  them.  The  commune  earns 
directly  more  than  500,000  francs  annually  through  the  keeping  of  the  lunatics,  and  in- 
directly also  a  great  deal  through  the  cheap  work  of  ail  kinds  which  the  patients  perform 
for  the  mhabitants.  It  is  the  personal  interest  of  the  inhabitants  to  do  their  duty  well 
by  the  patients,  as  these  are  intrusted  only  to  people  whose  moral  fitness  and  means  of 
existence  are  approved.  In  fact,  a  family  at  Gheel  is  not  considered  respectable  if  luna- 
tics are  not  intrusted  to  it,  and  the  withdrawal  of  them  from  its  care  constitutes  a  heavy 
punishment.  The  children  of  the  inhabitants,  living  from  their  earliest  childhood  with 
lunatics,  become  attached  to  them,  do  not  find  anything  ridiculous  in  them,  learn  how 
they  are  to  be  treated,  exercise  through  their  company  a  very  soothing  influence  on  them, 
and  are,  of  course,  not  in  the  least  afraid  of  them.  When  young  people  get  married 
they  ask  from  the  authorities  as  a  favor  and  a  sort  of  dowry  the  care  of  a  patient.  On 
their  arrival  at  Gheel,  the  lunatics  are  kept  at  the  central  asylum  for  observation  as  long 
as  the  director  deems  necessary.  In  case  of  acute  disease  they  are  brought  back  there. 
It  also  serves  as  the  house  of  correction,  the  privation  of  liberty  being  felt  as  a  severe  pun- 
ishment by  the  patients.  In  cases  of  great  debility  they  are  also  brought  there.  Many 
lunatics,  when  feeling  the  approach  of  a  paroxysm,  demand  themselves  to  be  sent  to  the 
asylum.  When  a  cure  has  been  effected,  the  caretaker  receives  as  a  reward  another  pa- 
tient, and  if  many  cui-es  occur  at  his  house  he  is  rewarded  with  the  care  of  a  wealthy 
patient.  The  number  of  cures  averages  from  sixty-five  to  seventy-five  out  of  the  hun- 
dred. Patients  with  radically  immoral  or  highly  dangerous  tendencies  cannot  be  kept 
at  Gheel,  the  central  asylum  being  only  a  depot.  The  number  of  lunatics  under  tempo- 
rary coercion  is  generally  twelve  out  of  the  1300. 

W^e  visited  now  the  infirmary,  the  cells,  and  the  halls,  where  the  lately  arrived  are  kept 
under  observation.  The  very  dirty  patients,  who  cannot  be  placed  with  the  inhabitants, 
have  their  own  rooms,  with  suitable  arrangements.  We  found  everywhere  exquisite 
cleanliness,  and  good  air  and  light;  the  patients  seemed  to  relish  their  dinner  well ;  they 
enjoy,  even  in  the  asylum,  a  great  deal  of  liberty,  and  if  a  lunatic  asylum  could  be  called 
a  cheerful  place,  the  one  at  Gheel  is,  perhaps,  the  only  one  to  which  that  term  could  be 
applied.  Good  paved  roads  traverse  the  commune,  and  many  houses  are  really  fine 
villas,  with  large  gardens  in  the  rear.  The  first  house  which  we  visited  was  the  house 
of  poor  people.  We  found  the  family,  composed  of  man,  wife,  and  three  young  chil- 
dren, and  their  two  lunatic  boarders,  seated  round  the  table  at  dinner.  The  children 
seemed  to  be  quite  unaware  that  they  were  sitting  at  the  side  of  lunatics,  nor  would  a 
stranger  entering  unprepared  ever  have  thought  of  the  presence  of  such  persons.  After 
some  more  visits  of  the  kind,  we  went  to  the  principal  tavern,  to  which  a  fine  large  hall 


TREATMENT   OF    INSANITY.  223 

is  attached,  where  there  are  fStes,  concerts,  and  dancing  every  Sunday,  Some  of  the 
houses  of  the  wealthier  classes  were  now  visited.  They  offer  all  the  comforts  that  can 
be  desired  for  ladies  and  gentlemen.  The  apartments  are  large,  well  furnished,  and  the 
patient  may  install  in  them  librari-es  and  whatever  is  allowed  by  the  director.  We  found 
there  persons  of  very  high  social  rank,  and  others  of  great  accomplishments.  In  the 
streets  we  met  at  every  moment  lunatics  lounging  before  the  doors  of  the  houses,  smoking 
pipes  or  cigars,  playing  with  the  children,  or  otherwise  amusing  themselves.  Among  the 
wealthier  class  of  patients  at  Gheel  it  is  nothing  uncommon  to  find  persons  who  spend 
there  from  ;^300  to  ^600  a  year.  Some  keep  cars  and  horses  for  their  use.  The  au- 
thorities watch  carefully  that  the  patients  are  not  imposed  upon,  and  that  they  receive  its 
value  for  the  money  which  they  spend.  Cases  of  misconduct  of  any  kind  toward  a 
patient  are,  however,  exceedingly  rare,  and  the  punishment  of  being  declared  unworthy 
to  keep  patients  is  considered  a  fearful  disgrace.  We  visited  the  Church  of  St.  Dymphne, 
the  Irish  princess  and  protectress  of  the  lunatics.  In  the  seventh  century  there  existed 
on  the  spot  a  chapel  dedicated  to  St.  Martin,  surrounded  by  a  dozen  houses  forming  then 
the  village  of  Gheel.  The  style  of  building  of  the  present  very  spacious  church  points 
to  the  twelfth  century,  the  time  of  transition  from  the  Roman  to  the  Gothic  style.  Some 
parts,  however,  were  added  later.  The  central  chapel  of  the  diambulatorium  contains 
a  remarkable  work  of  art,  the  history  of  St.  Dymphne,  carved  in  wood.  It  is  divided  into 
eight  parts.  The  figures,  painted  and  gilt,  are  of  good  proportions,  and  the  faces  won- 
derfully expressive.  The  parts  represent :  i.  The  birth  of  St.  Dymphne,  who  is  handed 
over  by  her  mother  to  St.  Gerebert.  2.  The  death  of  the  Queen,  the  mother  of  St. 
Dymphne.  3.  The  devil  suggesting  bad  thoughts  to  her  father,  the  Irish  king.  4.  St. 
Dymphne  embarking  with  St.  Gerebert  for  Belgium.  5.  The  king  seeking  his  daugh- 
ter. 6.  The  wicked  king  who  has  had  St.  Gerebert  beheaded,  beheading  himself  hzs 
daughter,  as  nobody  else  would  serve  as  executioner.  7.  Priests  carrying  in  procession 
the  relics  of  St.  Dymphne.  8.  A  demon  leaving  the  head  of  a  lunatic  woman,  cured  by 
prayer,  and  a  lunatic  in  chains  waiting  his  turn  for  deliverance.  I  ought  to  add  that 
during  our  visit  we  met  from  the  excellent  director,  Dr.  Bulckens,  the  parish  priest,  and 
everybody  we  came  in  contact  with,  the  most  exquisite  courtesy  and  willingness  to  give 
us  information. 

Mechanical  Restraint  and  Seclusion. — Respecting  the  question  of 
non-restraint  in  the  treatment  of  insanity,  I  think  it  is  possible  to 
bring  the  treatment  of  the  insane  to  that  state  of  development  when 
all  mechanical  restraint  may  be  dispensed  with  advantageously.  I 
feel  sure  that  the  complete  non-restraint  system  will  be  adopted  in 
future,  but  the  necessary  conditions  for  this  are  that  our  asylums 
must  not  be  overcrowded,  as  they  are  to-day,  and  that  the  patients 
must  be  under  constant  medical  supervision.  Perfect  non-restraint 
has  been  adopted,  I  think,  at  Hamburg,  Gottingen,  Berlin  (Charite),, 
Halle,  Marburg,  Heidelberg,  Eberswalde,  Keppenheim,  Werneck, 
Munich,  and  Alt  Scherbitz,  besides  all  the  asylums  of  Switzerland; 
also  in  Scotland,  in  some  instances,  and  recently  in  England,  although 
in  the  latter  I  am  not  sure  that  the  unqualified  adoption  of  non-restraint 
has  met  with  success.  I  think,  wherever  the  system  of  non-restraint 
has  been  properly  carried  out,  there  have,  with  few  exceptions,  no  doubts 
been  e?itertained  of  its  advantages  in  the  treatment  of  mental  disorders. 


224  PSYCHOLOGICAL   MEDICINE. 

Respecting  the  home  treatment  of  private  patients  in  private 
dwellings,  Dr.  Henry  Maudsley  says,  referring  to  the  condition  of 
the  numerous  chancery  patients  in  England  who  are  living  in  private 
houses  :  "  I  have  the  best  authority  for  saying  that  their  condition  is 
eminently  satisfactory,  and  such  as  it  is  impossible  it  could  be  in  the 
best  asylum,"  Dr.  Bucknill,  in  his  recent  essay,  "  On  the  Care  of  the 
Insane,  etc.."  speaks  as  follows  respecting  the  private  care  of  the  in- 
sane, and,  as  I  think,  very  wisely  :  "  It  is  not  merely  the  happy 
change  which  takes  place  in  confirmed  lunatics  when  they  are  judi- 
ciously removed  from  the  dreary  detention  of  the  asylum  into  domes- 
tic life,  it  is  the  efficiency  of  the  domestic  treatment  of  lunacy  during 
the  wJiole  course^'  of  the  disease  which  constitutes  its  greatest  value, 
and  of  this  the  author's  fullest  and  latest  experience  has  convinced 
him,  that  the  curative  influences  of  asylums  have  been  vastly  over- 
rated, and  that  those  of  isolated  treatment  in  domestic  care  have  been 
greatly  undervalued." 

Respecting  the  treatment  of  the  insane  without  mechanical  re- 
straint,t  Dr.  Henry  Maudsley  says : 

It  should  be  borne  clearly  in  mind  that  the  abolition  of  mechanical  restraint  is  not  itself 
a  principle,  but  a  detail  of  practice  founded  on  the  principle  which  inspires  what  is  called 
the  non-restraint  system.  A  very  bad  system  of  moral  management  might  prevail  where 
no  actual  corporeal  restraint  was  used ;  and,  on  the  other  hand,  it  is  possible,  though  not 
probable,  that  means  of  restraint  might  be  used  occasionally  and  yet  the  management  of 
patients  be  in  other  respects  good.  To  scold,  bully,  or  punish  an  insane  patient  would 
be  almost  as  injurious  to  him,  and  certainly  as  contrary  to  the  true  principle  of  the  non- 
restraint  system,  as  to  apply  mechanical  restraint.  Experience  proves  most  decidedly 
how  beneficial  is  the  influence  of  a  good  attendant,  how  pernicious  is  the  influence  of  a 
bad  attendant  on  a  patient  suffering  from  mental  disorder;  the  patient  will  degenerate 
under  the  influence  and  harsh  usage  of  an  ill-tempered  person  as  plainly  as  he  will  im- 
prove under  the  sympathy  and  gentle  behavior  of  a  kind  and  considerate  person.     He 

*  Italics  are  mine. 

■j-  Some  American  alienists  consider  that  the  English  run  great  risks  by  their  total  non- 
restraint,  and  that,  owing  to  insanity  being  of  a  more  severe  type  in  America,  that  total 
non-restraint  is  alike  unwise  and  oftentimes  prejudicial  to  the  best  interests  of  the  patient. 
— E.  C.  M. 

During  a  recent  visit  to  Philadelphia,  we  talked  with  Dr.  Henry  B.  Nunemaker  of 
the  Philadelphia  Hospital  for  the  Insane  upon  this  point,  and  he  seemed  to  be  decidedly 
of  the  opinion  that  insanity  is  gradually  assuming  a  milder  type  in  our  own  country, 
which  had  made  itself  very  manifest  during  the  past  five  years.  This  is  a  very  important 
fact,  as,  if  correct,  it  will  lead  rapidly  to  the  abolition  of  restraint.  It  has  been  claimed  that 
the  type  of  insanity  in  England  is  much  milder  than  with  us,  while  in  France,  it  approxi- 
mates more  nearly  the  American  t)'pe  of  insanity.  Climate  and  national  temperaments 
are  assigned  as  predisposing  causes  of  the  prevailing  type  in  any  country. 


TREATMENT    OF    INSANITY. 


225 


has  more  than  once  known  instances  of  patients  who  have,  without  exaggeration,  been 
cured  by  judicious  change  of  attendant.  The  greatest  of  difficulties,  indeed,  in  the  treat- 
ment of  the  insane,  is  to  obtain  suitable  persons  to  fill  this  trying  and  most  responsible 
position.  Qualities  of  head  and  heart  are  demanded  such  as  would  secure  for  their  pos- 
sessor higher  remuneration  and  less  onerous  duties  in  a  more  eligible  vocation.  The 
accidents  and  injuries  in  asylums,  which  have  lately  excited  so  much  attention,  have  in- 
dicated the  weak  point  in  asylum  management — the  want  of  a  properly  trained  and  high 
class  of  attendants,  and  of -an  adequate  supervision  of  these  immediate  guardians  of  the 
insane  by  officers  of  a  higher  standing.  It  is  to  be  feared  that  patients  are,  in  some  in- 
stances, left  too  much  at  the  mercy  of  attendants.  Now,  to  place  an  insane  person  at 
the  mercy  of  a  coarse,  violent,  and  ignorant  attendant  is  to  adopt  the  surest  way  of  ren- 
dering him  furious,  unmanageable,  and  finally  incurable.  With  his  delusions  of  suspicion 
or  fear  he  mingles  inseparably  the  realities  of  the  treatment  to  which  he  is  subjected,  and 
if  this  be  at  all  harsh  and  unsympathetic  he  naturally  becomes  furious,  and  resists  it  with 
all  the  energy  of  his  frenzy.  His  delusions  are  thus  strengthened  and  fixed ;  whereas, 
by  gentle  usage  and  sympathetic  attention,  his  confidence  is  gained  and  they  are  gradu- 
ally undermined.  Angry  usage — nay,  even  an  angry  word — sometimes  does  incalculable 
mischief.  It  is  easy  to  perceive  that  if  a  patient  imagines  himself  to  be  in  hell  or  about 
to  be  murdered,  and  those  around  him  to  be  devils  or  murderers,  as  happens  now  and 
then,  he  is  not  likely  to  be  disabused  of  his  morbid  idea  by  devil-like  treatment.  The 
principle  of  the  non-restraint  system,  in  the  true  acceptation  of  the  term,  is,  whilst  avoid- 
ing a  meddlesome  interference,  to  make  all  the  surroundings  of  the  poor  lunatic  as  tran- 
quil, as  orderly,  as  gentle  as  may  be  consistent  with  his  proper  care,  to  counteract  the 
commotion  in  him  by  an  absence  of  commotion  in  what  is  around  him.  The  lunatic 
cannot,  any  more  than  the  sane  person,  resist  the  steady  influence  of  his  surroundings;  he 
assimilates  them  unconsciously,  and  they  modify  his  character  for  good  or  for  evil. 

How  little  a  system  of  mechanical  restraint  fulfils  the  conditions  of  the  just  principle 
of  treatment  is  so  plain  that  a  wayfaring  man,  though  a  fool,  can  hardly  fail  to  see  it. 
An  excited,  active  patient,  urged  by  an  uncontrollable  instinct  of  movement,  desiring  and 
needing,  above  all  things,  freedom  of  limbs,  is  secured,  hand  and  foot,  by  inechanical 
appliances;  with  what  result?  That  he  is  provoked  into  furious  mania,  expends  his 
energy  in  shouting  and  raving,  and  becomes  dirty  in  his  habits.  Dirtiness  in  some  shape 
is,  in  fact,  unavoidable  under  such  circumstances.  But  it  may  be  argued,  as  it  is  some- 
times argued,  that  it  would  be  better  for  the  patient  to  be  so  restrained  mechanically  than 
to  be  restrained  by  the  efforts  of  attendants  who,  in  the  excitement  of  struggling,  are  apt 
to  overpass  the  limits  of  a  temperate  exercise  of  force,  and  to  proceed  to  passionate  acts 
of  violence.  No  doubt,  if  it  were  necessary  to  have  such  struggles  where  restraint  was 
not  used,  and  not  necessary  to  have  them  in  order  to  apply  restraint,  there  would  be 
something  to  be  said  in  favor  of  its  use.  But  it  is  very  seldom  necessary  to  have  a  physi- 
cal contest  with  a  patient ;  indeed,  if  contests  of  the  kind  were  of  frequent  occurrence,  it 
would  be  strong  evidence  of  a  bad  moral  tone  in  the  management,  and  of  a  neglect  of 
proper  medical  treatment.  If  the  whole  treatment  of  acute  insanity  consisted,  as  some 
persons  seem  to  imagine,  in  mastering  the  patient  by  physical  force  and  in  endeavoring  to 
stifle  excitement  by  means  of  opium  and  other  sedatives,  there  can  be  little  doubt  that 
violent  struggles  and  restraint,  in  some  form  or  other,  would  be  found  necessary.  But  if 
an  indiscriminate  use  of  sedatives  be  avoided  and  a  rational  medical  treatment  be  directed 
to  the  bodily  disorder  which  will  commonly  be  found  to  accompany  mental  derangement, 
and  if,  furthermore,  the  moral  management  be  sympathetic  and  prudent,  it  will  be  seldom 
necessary  to  resort  to  physical  violence. 

Let  it  not  be  supposed,  moreover,  that  the  imposition  of  mechanical  restraint  does  away 

15 


226  PSYCHOLOGICAL   MEDICINE. 

with  scenes  of  violence.  Far  from  it;  it  encourages  them.  Much  violence  must  usually 
be  used  in  order  to  apply  the  means  of  restraint,  a  desperate  contest  occurring  before  the 
patient  is  overpowered  and  left  helpless,  exhausted,  and  furious,  with  a  bitter  sense  of 
degradation.  Such  straggles  breed  similar  struggles,  and  the  restraint  used  necessitates 
a  frequent  recurrence  to  it.  There  can  be  no  greater  fallacy  than  that  of  supposing  what 
is  called  a  moderate  use  of  mechanical  restraint  to  be  consistent  with  a  general  plan  of 
treatment  in  other  respects  humane  and  beneficial.  It  must  be  dispensed  with  altogether, 
or  deterioration  will  ensue  in  the  patient,  and  all  kinds  of  neglect  and  tyranny  will  be 
engendered  by  degrees,  until  restraints  become  the  usual  substitutes  for  forbearance  and 
watchful  attention.  As  one  great  argument  against  slavery  was  that  it  demoralized  the 
slaveholder,  so  a  very  bad  effect  of  the  employment  of  restraint  in  dealing  with  the  insane 
is  that  it  demoralizes  attendants.  And  on  this  ground,  if  there  were  no  other  grounds,  it 
is  necessary  that  the  abolition  of  restraint  should  be  absolute  to  be  efficient;  the  principle 
of  the  non-restraint  system  will  admit  of  no  compromise. 

It  must  be  allowed  that  when  called  to  treat  an  acute  case  of  insanity  in  a  private 
house,  it  is  not  always  so  easy  to  do  without  restraint  as  it  is  in  an  asylum,  where  there 
are  suitable  appliances  for  meeting  the  difficulties  which  the  excitement  and  violence  of 
a  patient  may  present.  But  if  a  medical  man  finds  it  absolutely  necessary  to  employ 
mechanical  restraint,  he  should,  if  he  has  the  welfare  of  his  patient  at  heart,  send  him 
elsewhere,  for,  either  it  is  not  a  fit  case  for  private  treatment  or  he  is  without  the  requisite 
assistance  and  qualifications  for  treating  it  properly.  The  attendants  on  whom  he  de- 
pends are  probably  ignorant  and  incompetent. 

It  should  be  clearly  understood  by  those  who  feel  any  doubt  of  the  value  of  the  non- 
restraint  system  that,  although  it  is  not  fully  adopted  in  foreign  asylums,  it  has  been 
warmly  advocated  by  the  most  eminent  foreign  alienists  who  have  witnessed  it  in  opera- 
tion in  English  asylums.  Morel,  of  Rouen,  after  living  some  time  in  an  English  asy- 
lum, in  order  to  make  himself  practically  acquainted  with  its  working,  became,  and 
has  since  been,  one  of  its  warmest  supporters.  The  late  Professor  Greisinger,  who, 
once  an  opponent  of  non-restraint,  made  a  journey  to  this  country  especially  to  exam- 
ine into  its  merits  and  alleged  demerits,  became  an  earnest  defender  of  it,  and  applied 
it  with  great  success  in  the  asylum  connected  with  the  Charite  at  Berlin.  Ludwig 
Meyer  introduced  it  with  the  most  beneficial  results  into  the  asylum  at  Hamburg,  over 
which  he  formerly  presided.  Others  have  followed  and  are  following  in  the  wake  of  these 
distinguished  men.  With  such  testimony  coming  from  abroad,  it  is  somewhat  sad  to  find 
that  doubts  should  arise  in  the  country  in  which  the  non-restraint  system  had  its  birth  and 
has  attained  its  fullest  development.  Our  author  cannot  think  that,  in  face  of  the  irrefu- 
table evidence  of  experience,  they  will  have  a  long  vitality,  and  he  certainly  does  not 
hesitate  to  express  a  strong  personal  conviction  that  the  use  of  mechanical  restraint  in 
any  asylum,  public  or  private,  is  an  indication  of  a  badly-managed  institution,  and  that 
its  use,  m  the  treatment  of  private  cases,  is  unnecessaiy  and  prejudicial.  Where  it  is 
entirely  dispensed  with  there  will  be  less  excitement,  fewer  scenes  of  violence,  less  need 
of  secluding  patients,  and  earlier  and  more  numerous  recoveries  than  where  it  is  in  use. 
For  it  is  not  only  an  evil  itself,  but  it  is  the  fruitful  parent  of  a  multitude  of  ills,  not 
the  least  of  which  is  the  certain  deterioration  of  all  who  have  any  part  in  its  employ- 
ment, whether  suffering  or  doing. 

The  late  Dr.  Isaac  Ray,  of  Philadelphia,  in  writing  on  the  manage- 
ment of  hospitals,  speaks  thus  of  mechanical  restraint  and  seclusion, 
and  the  general  welfare  of  the  insane : 


TREATMENT   OF    INSANITY.  22/ 

The  reformer's  creed  frequently  contains  but  a  single  article  of  belief,  namely,  this : 
because  a  thing  is  bad,  therefore  the  directly  opposite  thing  is  necessarily  good.  The 
effect  of  this  fallacy  has  been  strikingly  manifested,  for  instance,  in  the  controversy,  not  yet 
settled,  respecting  mechanical  restraint  as  applied  to  the  insane.  Everybody  admits  that 
it  has  been  grossly  abused,  but  an  immense  difference  prevails  as  to  the  practical  infer- 
ence that  should  be  drawn  from  the  fact.  While  it  leads  one  party  to  use  it  for  proper 
purposes  and  in  a  judicious  manner,  so  as  to  secure  its  benefits  and  avoid  its  evils,  it 
leads  another  to  disuse  it  altogether  as  an  unmitigated  wrong.  Of  course,  abundant  rea- 
sons are  offered  for  the  correctness  of  each  of  these  conclusions,  and  they  are  not  without 
their  force;  but — in  accordance  with  a  common  phasis  of  belief — they  have  probably 
less  to  do  with  actual  opinions  than  a  state  of  feeling  antecedent  to  all  reasons.  This 
accounts  for  the  difficulty  of  arriving  at  the  truth  in  all  questions  of  practical  reform  ;  but 
the  number  of  those  who  learn  from  it  a  lesson  of  caution  against  hasty  conclusions  will 
always  be  small.  In  the  present  case  there  is  a  touch  of  the  romantic  in  the  idea  of 
managing  the  insane  entirely  without  mechanical  restraint,  and  solely  by  moral  suasion 
or  the  gentle  laying  on  of  hands ;  and  when  first  announced  it  is  not  strange  that  it  was 
taken  at  once  into  public  favor.  It  had  all  the  eclat  of  a  great  discovery,  worthy  of  being 
compared  with  that  of  anesthetics  or  the  vaccine  virus;  and  in  England,  where  it  origi- 
nated, it  needed  more  than  an  average  share  of  moral  courage  to  regard  it  with  the  slight- 
est distrust. 

One  thing  leads  to  another ;  and  the  idea  of  complete  non-restraint  was  followed,  in 
the  fulness  of  time,  by  that  of  banishing  all  those  distinctive  architectural  arrangements 
supposed  to  be  indispensable  to  the  proper  care  and  custody  of  the  insane.  Open  fires 
on  the  hearth,  windows  without  guards,  and  doors  without  locks,  have  been  adopted  in 
one  or  two  hospitals  lately  erected  in  England.  It  is  not  surprising  that  men  of  a  san- 
guine, philanthropic  temper,  should  hail  such  innovations  with  their  warmest  approval, 
and  that  under  the  pressure  of  public  sentiment  they  should  be  sustained,  temporarily  at 
least,  at  all  hazards.  The  careful  observer,  who  studies  insanity  like  any  other  object  of 
scientific  investigation,  will  hardly  be  satisfied  with  the  reasons  offered  for  such  a  radical 
reform ;  and  though  willing  to  accept  results  as  the  proper  tests  of  their  soundness,  he 
will  require  that  the  experiment  shall  be  tried  on  a  large  scale,  by  various  parties,  and 
its  indirect  and  contingent,  as  well  as  immediate  results,  be  fairly  taken  into  the  ac- 
count. No  experiment  in  the  management  of  the  insane  can  be  considered  successful, 
merely  because  no  indications  of  failure  are  visible  for  a  limited  period,  or  under  peculiar 
circumstances.  For  the  very  object  may  be,  not  to  prevent  an  evil  which  otherwise 
would  be  sure  to  happen,  but  to  meet  a  contingency  that  may  never  occur.  The  mere 
fact  that  it  does  not  occur  has  no  necessary  connection  with  the  means  of  prevention. 
No  one  at  all  conversant  with  hospitals  for  the  insane  can  have  failed  to  see  that,  in  some 
degree,  their  results  are  apparently  a  matter  of  chance.  To  attribute  them  entirely  and 
exclusively  to  management  would  be  no  mark  of  wisdom.  The  man  who  congratulates 
himself  on  the  success  of  his  measures  for  preventing  suicide,  on  account  of  entire  ex- 
emption for  several  years,  will  find  his  self-complacency  somewhat  ruffled  when,  without 
any  change  of  practice,  several  cases  occur  in  rapid  succession.  So,  too,  he  may  find 
that  the  large  proportion  of  recoveries,  and  the  small  proportion  of  deaths  and  casualties, 
which  for  a  time  seemed  to  be  indisputable  proofs  of  his  skill,  are  attributable  to  causes 
over  which  he  had  little  or  no  control.  Now,  to  ascertain  how  far  this  element  of  chance 
prevails,  must  always  be  a  work  of  time;  and  we  may  fairly  challenge  the  soundness  of 
any  conclusions  where  sufficient  account  has  not  been  made  of  its  influence. 

Another  error  very  incident  to  measures  of  reform  in  our  specialty  is  to  mistake  indi- 
vidual traits  for  general  conditions,  and  thus  conclude,  prematurely,  that  what  is  appli- 


228  PSYCHOLOGICAL   MEDICINE. 

cable  to  one  case  is  no  less  applicable  to  all.  Diversities  of  disease,  of  previous  manage- 
ment, of  natural  character,  may  all  be  ignored,  and  some  procrustean  plan  regarded  as 
embodying  all  the  wisdom  worth  retaining.  A  patient  long  subjected  to  mechanical 
restraint  improves  under  its  disuse ;  therefore  no  patient  requires  it,  and  complete  non- 
restraint  must  be  the  unexceptionable  rule.  Another  is  annoyed  by  the  sight  of  locks 
and  guards,  which,  in  fact,  are  unnecessary  for  him ;  therefore  they  are  annoying  to  all 
and  unnecessary  for  any.  Another  desires  to  go  out  unattended,  and  undoubtedly  is  all 
the  better  for  the  privilege;  therefore  unrestricted  freedom  in  this  particular  should  be  the 
general  rule.  Deductions  like  these  may  seem  somewhat  puerile,  but  they  are  scarcely 
exaggerations  of  what  have  actually  been  made.  Now,  with  all  admiration  for  the  spirit 
underlying  these  projected  reforms,  I  am  still  obliged  to  doubt  whether  they  do  not  ex- 
hibit some  confusion  of  thought,  both  as  to  the  ends  which  are  proposed  and  the  condi- 
tions of  a  successful  experiment.  These  two  questions  it  may  be  well  to  consider  for  a 
moment,  beginning  with  the  latter. 

Morbid  movements  of  the  nervous  system  often  require  considerable  time  for  their 
completion,  and  are  marked  by  a  certain  periodicity  not  apparent  in  other  affections. 
What  we  happen  to  see  may  be  but  a  single  phasis  of  the  movement,  to  be  followed  by 
others  equally  prominent  before  the  morbid  cycle  is  completed.  What  it  may  reveal 
precisely,  we  cannot  predict  before  it  is  completed.  Now,  a  kind  of  management  that 
may  be  very  proper  in  regard  to  one  of  these  phases  may  not  be  so  in  regard  to  another, 
because  the  wishes  and  feelings  of  the  patient,  the  force  of  his  impulses  and  the  gravity  of 
his  disease,  may  present  the  utmost  possible  difference.  An  inflexible  rule  of  manage- 
ment, by  ignoring  these  diversities,  must  necessarily  occasion  much  mischief,  directly  or 
indirectly;  and  not  more  does  the  individual  differ  from  himself  at  different  periods, than 
does  the  general  condition  of  the  house.  The  expediency  of  non-restraint,  for  instance, 
might  be  very  differently  manifested,  even  in  the  same  establishment,  at  different  periods, 
inasmuch  as  several  months  of  complete  disuse  of  restraint  might,  very  properly,  be  fol- 
lowed by  as  long  a  period  of  its  abundant  use.  We  should  not  suppose  we  had  cured  a 
case  of  epilepsy  or  hysteria  merely  because  the  period  since  the  last  fit  has  been  much 
longer  than  any  previous  interval ;  or  that  a  maniacal  patient  had  recovered,  because  the 
high  excitement  had  passed  away  and  he  replied  to  a  few  questions  correctly ;  why,  then, 
should  we  be  required  to  accept  any  principle  of  management  which  has  been  tried, 
however  successfully,  on  a  limited  scale  and  for  a  limited  period  ?  It  is  no  satisfactory 
reply  to  the  patent  objections  that  lie  against  this  or  that  aiTangement,  to  say  that  no  harm 
has  arisen  from  it,  so  far.  Great  care,  aided  by  great  good  luck,  may  unquestionably  save 
us  sometimes  from  the  legitimate  effects  of  a  faulty  arrangement.  But  in  any  provision 
relative  to  the  management  of  the  insane,  it  should  be  implicitly  required  that  its 
operation  should  depend  as  little  as  possible  on  the  chances  of  fortune  or  the  short- 
comings of  men.  Its  merit  should  consist,  in  a  great  measure,  in  its  independence 
of  these  contingencies.  Success,  in  spite  of  manifest  danger,  would  be  a  very  feeble 
argument  in  favor  of  repeating  the  experiment.  To  say  of  it  that  we  have  got  along 
under  it  without  any  untoward  event,  is  to  render  but  a  vulgar  estimate  of  success, 
though  one  most  intelligible,  perhaps,  to  the  multitude.  Let  us  bear  in  mind,  too, 
that  a  broader  field  of  trial,  a  wider  scope  of  comparison,  a  more  impartial  judg- 
ment of  results,  is  necessary,  than  any  single  individual  can  fairly  claim. 

Much  error  has  been  committed  on  this  subject,  in  consequence  of  misunderstanding 
the  proper  ends  of  any  reformatory  measure  in  the  management  of  the  insane.  The  phil- 
osophical test  of  social  and  political  reform — the  greatest  happiness  of  the  greatest  number 
— must  not  be  exclusively  adopted  here.  A  provision  is  not  to  be  hastily  discarded  merely 
because  it  has  been  attended  by  abuses,  or  because  its  evils,  on  the  whole,  seem  to  over- 


TREATMENT   OF    INSANITY.  229 

balance  its  benefits.  The  careful  inquirer  will  first  ascertain  whether,  by  some  adminis- 
trative change,  the  former  may  not  be  prevented,  and  the  latter  retained.  To  give  up  a 
provision  which  is  known  to  serve  an  excellent  purpose,  because  in  the  hands  of  the 
careless  and  heartless  it  has  been  made  an  instrument  of  wrong,  may  be  wise  under  some 
circumstances,  but  can  hardly  be  considered  a  triumph  of  professional  skill.  True  sci- 
ence, true  skill,  consist  in  meeting  the  exigencies  of  each  particular  case ;  and  though 
these  must  sometimes  be  subordinate  to  the  general  good,  this  necessity  must  be  regarded 
as  a  defect  rather  than  a  merit.  The  question  we  have  to  deal  with  is,  how  we  can  best 
reach  the  needs  of  each  one  of  those  individuals  who  make  up  the  collective  body  under 
our  charge;  and  so  long  as  we  keep  this  end  before  us,  we  may  be  sure  we  are  on  the 
right  course.  When,  however,  we  strive  after  something  above  and  beyond  this,  seek- 
ing, for  instance,  to  establish  some  general  rule  or  practice  calculated  to  strike  the  fancy 
and  to  win  the  applause  of  the  inconsiderate,  there  is  great  danger  that  the  other  and 
more  important  end  will  come  to  hold  an  inferior  place  in  our  regard.  There  may  be- 
no  incompatibility  between  these  ends,  for  many,  I  doubt  not,  are  steadily  keeping  them 
both  in  view ;  but  there  is  a  natural  tendency  to  seek  that  which  is  most  easily  appre- 
ciated by  all  who  look  only  on  the  outside,  and  which,  by  such,  would  be  regarded  as  in- 
dicative of  originality  and  vigor.  We  see  it  in  the  idea,  too  often  put  forth,  of  claiming 
merit  for  encountering  great  risks  with  but  little  actual  damage.  So  many  epileptics 
have  frequented  a  room  having  an  open  fire,  so  many  uneasy,  discontented  patients  have 
been  allowed  to  go  and  come  as  they  please,  so  many  pugnacious  ones  have  mingled 
freely  with  the  rest,  so  many  homicidal  ones  have  been  intrusted  with  edge-tools ;  and 
yet  nobody  has  fallen  into  the  fire,  nobody  has  eloped,  nobody  has  been  struck,  nobody 
has  been  killed  or  wounded.  As  if  such  a  result  might  not  possibly  have  been  a  re- 
markable instance  of  good  fortune  rather  than  the  sign  and  seal  of  a  blessed  reform  ; 
and  as  if  the  welfare  of  the  individual  patient  were  a  matter  of  little  concern  compared 
with  the  working  of  a  general  rule.  I  would  not  be  understood  as  saying,  that  in  the 
management  of  the  insane  we  are  to  incur  no  risks  whatever;  in  other  words  that  we 
are  to  withhold  from  them  every  privilege  and  the  slightest  measure  of  freedom,  be- 
cause they  might  possibly  abuse  them.  The  whole  theory  of  modern  management 
implies  risk,  to  be  avoided,  however,  as  much  as  possible,  by  the  exercise  of  discern- 
ment and  tact.  Sometimes,  indeed,  a  desirable  end  can  be  obtained  only  through 
more  or  less  risk,  and  on  the  general  question  there  can  be  but  one  opinion.  But  such 
risks  must  be  carefully  distinguished  from  those  which  involve  the  welfare  of  others,  or 
tend  only  to  glorify  individuals.  If  an  attempt  to  benefit  a  particular  patient  by  some 
exercise  of  risk,  applicable  solely  to  him,  fail,  he  alone  is  affected  ;  and  if  the  circum- 
stances fairly  justified  the  attempt,  he  cannot  complain.  But  if,,  while  it  is  applied  to 
one  person,  its  consequences  fall  upon  another,  then  the  latter  has  good  reason  to  be 
aggrieved.  When  a  sanguine  believer  in  non-restraint  systematically  exposes  his  pa- 
tients to  the  assaults  of  those  who  are  inclined  to  such  mischief,  in  the  vain  expectation 
that  any  practical  amount  of  vigilance  can  obviate  actual  harm,  he  will  hardly  be  able 
to  justify  the  occurrence  of  unpleasant  casualties  by  pleading  the  common  good.  The 
sufferers  would  reply,  and  very  properly  too,  that  they  were  placed  under  his  care  for 
their  own  particular  good,  and  not  for  the  purpose  of  enabling  him  to  work  out  some  fa- 
vorite theory.  And  they  might  also  say  that  they  were  so  placed,  mainly  for  the  purpose 
of  being  saved  from  themselves  and  others. 

I  believe  that  the  reasons  urged  in  favor  of  some  of  these  reformatory  measures  are 
founded  in  incorrect  notions  of  insanity,  and  especially  of  the  thoughts  and  feelings  of 
the  insane.  It  is  contended  that  the  safeguards  which  have  been  placed  around  the  pa- 
tient should  be  removed,  because  they  are  supposed  to  annoy  him  by  constantly  remind- 


230  PSYCHOLOGICAL   MEDICINE. 

ing  him  of  his  infirmity,  and  proclaiming  from  ever}'  door  and  window  that  he  cannot  be 
trusted.  Unquestionably,  in  a  small  proportion  of  cases,  restraint  of  any  kmd  is  disa- 
greeable, and,  perhaps,  unnecessary' ;  but  it  is  equally  certain  that  to  many  patients  it 
is  not  even  a  source  of  discomfort.  The  latter  class  have  an  habitual  sense  of  insecurity, 
fear  to  be  left  to  themselves,  and  welcome  the  means  of  restraint.  Many  of  those,  even, 
whose  form  of  disease  is  marked  by  high  excitement,  feel  at  times  a  consciousness  that 
they  are  unfit  to  be  at  large,  and  recognize  the  necessity  of  those  abridgments  of  their 
freedom  which  a  hospital  involves.  Much  of  the  repugnance  which  the  insane  are  sup- 
posed to  feel  to  the  restrictive  arrangements  of  a  hospital  may  be  fairly  attributed  rather 
to  that  captious,  fault-finding  spirit  so  common  in  the  disease,  than  to  any  keen  sensibili- 
ties in  the  matter. 

When  restraint  of  any  kind  is  required,  let  it  be  applied,  we  are  told,  by  the  look  and 
the  touch  of  an  attendant,  not  by  barbarous  implements  of  wood  and  iron.  Mistakes  have 
been  made,  no  doubt,  as  to  the  amount  of  interference  compatible  with  the  best  interests 
of  the  insane,  but  we  ought  not  to  err  very  widely  as  to  the  amount  of  care  and  vigilance 
that  may  be  reasonably  expected  of  attendants.  Natural  disposition  and  temperament, 
tact  and  culture,  may  affect  the  result  somewhat,  but  we  well  know  that  beyond  a  cer- 
tain point  these  qualities,  in  their  best  estate,  are  perfectly  impotent.  For  a  short  period 
and  an  imminent  emergency,  we  may  be  warranted  in  relying  upon  them  implicitly.  But 
lengthen  the  period,  or  render  the  contingency  more  remote  and  uncertain,  and  to  that 
extent  personal  vigilance  becomes  unreliable.  An  attendant  placed  in  charge  of  a  pa- 
tient incessantly  bent  on  self-destruction  may  be  safely  relied  on  for  several  hours ;  but 
let  it  be  his  sole  business  to  prevent  a  patient  from  striking  when  the  impulse  comes, 
which  may  be  but  once  in  two  or  three  months,  and  who  that  knows  anything  of  the 
subject  supposes  that  the  blow  will  not  be  struck  at  last?  The  continuity  of  attention 
required  for  this  purpose  may  not  be  impossible,  but  in  practice  it  would  be  idle  to  ex- 
pect it.  In  fact  there  is  really  no  relation  between  the  ends  and  the  means.  The  question 
is  not  which  of  the  two  kinds  of  restraint,  personal  or  mechanical,  is  preferable  in  this 
case,  but  whether  the  latter  is  not  the  only  one  capable  in  the  nature  of  things,  of  effecting 
the  purpose.  Considering  the  matter  in  reference  to  its  immediate  effects  on  the  patient, 
and  unconnected  with  theories  or  biases,  it  seems  difficult  to  conceive  how  there  could 
be  two  opinions  about  it.  And  in  the  class  of  cases  where  either  would  be  admissible,  I 
have  been  led  by  twenty  years'  experience  to  believe  that  a  simple  contrivance  of  leather 
or  cloth  placed  on  the  limbs,  performing  its  service  quietly  and  steadily.,  is  infinitely  pref- 
erable to  an  array  of  attendants  holding  the  hands  and  feet,  and  at  every  relaxation  of 
their  efforts  provoking  renewed  straggles  from  the  patient. 

It  has  been  of  late  years  somewhat  fashionable  to  ignore  some  prominent  traits  of  in- 
sanity, or  at  least  to  suppose  that  they  may  be  kept  in  abeyance  by  devices  of  manage- 
ment. The  insane  should  be  treated  more  like  the  sane,  trusted  with  responsible  duties, 
and  thrown  much  upon  their  own  power  of  self-control.  No  one  would  dissent  from  the 
general  principle  implied  in  this  statement,  because  it  is  characteristic  of  all  humane  and 
intelligent  management ;  but  unquestionably  some  have  been  disposed  to  carry  it  to  an 
almost  unlimited  extent.  Among  them  was  one  whose  name  was  intimately  associated 
with  the  histor}'  of  our  specialty  in  this  countrj'.  His  practice  was  to  treat  his  patients 
as  if  governed  by  the  principles,  motives,  and  impulses  of  sane  men,  until  the  contrary 
appeared.  Very  brilliant  results  sometimes  followed  this  management,  and  some  not  so 
well  calculated  to  recommend  it  for  general  adoption.  He  was  fond  of  taking  visitors 
to  a  window  and  showing  them  three  or  four  patients  mowing  together  in  an  adja- 
cent field,  all  of  whom  had  committed  homicide.  There  was  something  very  extraordi- 
nary, no  doubt,  in  such  an  exhibition.     To  those  who  are  governed  by  appearances  merely. 


TREATMENT   OF   INSANITY.  23  I 

it  indicated  the  triumph  of  the  strong  will  and  the  commanding  presence,  over  the  lower 
instincts  of  a  diseased  mind,  and  excited  the  usual  admiration  produced  by  the  mar- 
vellous. 

No  good  can  come  by  shutting  our  eyes  to  an  old  truth,  merely  because  it  is  old,  and 
believing  that  the  world  has  always  been  mistaken  in  the  idea  that  a  disposition  to  mis- 
chief is  a  frequent  element  of  insanity.  Tamed,  diverted,  modified  it  certainly  may  be ; 
but  there  can  be  no  graver  error  than  to  suppose  that,  by  any  system  of  treatment,  it  may 
be  utterly  extinguished.  And  even  if  it  were  possible  to  eradicate  this  element  of  the 
disease,  there  remains  another  which  should  prevent  us  from  relying  too  much  on  the 
discretion  of  the  insane.  The  guiding,  determining  power  of  the  patient — the  balance- 
wheel,  if  I  may  use  the  figure,  which  regulates  the  mental  niovement — is  generally  more 
or  less  impaired,  and  some  power  must,  to  that  extent,  take  its  place.  For  this  reason  the 
patient  is  taken  from  home  or  his  customary  surroundings,  where  he  is  following  the  bent 
of  his  disordered  fancies,  and  placed  where  his  liberty  of  action  is  greatly  curtailed,  and 
his  movements  directed  by  others.  To  some,  scarcely  anything  more  is  necessary  than 
the  unavoidable  restrictions  of  the  hospital.  In  others,  the  gravity  of  the  disturbing  ele- 
ment may  call  for  the  utmost  amount  of  restriction  at  our  disposal.  In  some  shape  or 
other,  restriction  is  an  essential  element  in  all  hospital  management  of  insanity ;  but  it 
would  be  preposterous  to  contend  that  just  so  much  or  so  little  is  the  exact  measure  best 
suited  to  all  cases  alike,  or  to  any  considerable  proportion. 

In  the  above  remarks  it  has  been  my  intention  to  indicate  the  only  channels  which  the 
course  of  improvement  can  possibly  take,  and  to  state  my  reasons  for  dissenting  from 
some  current  opinions  on  this  subject.  I  am  not  disposed  to  anticipate  only  failure  from 
the  most  skilfully  managed  experiments,  nor  to  regard  free  and  full  inquiry  in  any  direc- 
tion as  useless.  What  may  be  accomplished  hereafter  must  be  a  matter  of  speculation, 
but  probably  the  future  will  be  much  like  the  past.  Men  will  continue  to  jump  at  con- 
clusions, to  imagine  that  they  have  found  some  royal  road  to  the  desired  object,  and  that 
their  own  new  ways  are  better  than  any  old  ones.  One  project  after  another  will  pass 
away,  but  not  without  leaving  some  pregnant  suggestion  behind.  In  the  mean  time,  let 
us  be  less  anxious  to  discover  new  truths  than  to  turn  the  old  ones  to  the  best  possible 
account,  and  then  we  need  have  no  apprehension  that  the  dark  ages  will  return.  The 
latter  object  is  within  the  reach  of  all ;  the  former  is  reserved  for  the  gifted  few. 

The  subject,  which  is  of  great  importance,  applies  I  think  equally 
well  to  the  large  class  of  the  chronic  insane  who  are  incurable  and 
harmless  and  who,  under  the  official  inspection  of  the  State  Commis- 
sioner in  Lunacy,  could  advantageously  be  treated  in  private  fami- 
lies with  the  blessings  and  comforts  of  home  life,  and  with  important 
financial  results  to  the  commonwealth ;  and  this  would  at  once  re- 
lieve our  overcrowded  lunatic  asylums,  and  I  think  there  would  be 
a  difference  of  a  large  per  cent,  in  the  expenditure  to  the  State.  Our 
present  large  and  expensive  asylums  often  require  an  investment  of 
three  or  four  thousand  dollars  for  the  accommodation  of  every  indi- 
vidual patient,  and  aires,  where  such  large  masses  of  the  insane  are 
aggregated,  and  individuality  and  personality  lost,  cannot  reach  the 
same  per  cent,  as  when  the  physician  can  carefully  and  personally 
study  and  treat  each  individual  case.     In  order  that  the  system  I 


232  PSYCHOLOGICAL   MEDICINE. 

have  spoken  of  should  be  efficient,  the  person  taking  charge  of  an 
insane  patient  in  a  private  house  should  be  required  to  cause  the  pa- 
tient to  be  visited  at  least  once  a  fortnight  by  the  medical  attendant ; 
and  the  physician  who  makes  the  visit  should  be  obliged  at  each 
visit  to  enter  in  a  book,  to  be  kept  at  the  house,  the  date  of  his  visit 
and  also  the  state  of  health,  mentally  and  bodily,  of  the  patient,  and 
the  general  condition  and  the  circumstances  of  the  patient  and  the 
house.  A  duplicate  of  this  report  should  be  forwarded  by  the  phy- 
sician to  the  State  Commissioner  in  Lunacy  or  to  the  person  dele- 
gated by  him,  or  better  yet  to  a  regular  district  physician  in  lunacy, 
who  could  be  appointed  by  the  governor.  The  State  could  be  di- 
vided into  four  or  more  districts,  and  a  physician  in  lunacy  appointed 
for  each  district  by  the  governor.  This  board  of  physicians,  who 
should  be  specialists  in  nervous  and  mental  diseases,  could  constitute 
a  lunacy  commission  to  also  visit  and  report  as  to  the  condition  of 
lunatic  hospitals,  and  protect  the  rights  of  those  who  are  incarcerated 
in  public  asylums,  and  also  strongly  support  the  medical  superin- 
tendents who,  as  a  rule,  exhibit  skill  and  wisdom  of  the  highest 
order.  The  public  would  feel  more  assured,  perhaps,  that  no  evils 
or  abuses  could  spring  up  in  our  asylums,  and  also  that  if  there  is 
any  room  for  improvement  it  will  be  immediately  seen  by  the  com- 
mission in  lunacy  if  it  escapes  the  superintendent's  eye. 

The  Lunacy  Commission  of  Great  Britain  has  been  of  great  benefit 
both  to  the  officers  and  the  patients  of  the  English  institutions,  and 
would,  I  think,  do  the  same  in  our  own  country,  and  would  dispel 
the  prejudice  existing  against  our  asylums  and  their  managers.  Such 
a  commission  in  lunacy  could  also  instruct  the  public  as  to  the  pre- 
vention of  insanity,  etc.  As  there  is  a  lymch-needed  reform  as  to  a 
netu  vietliod  of  introducing  expert  testimony  in  criminal  tiials  where  in- 
sanity is  alleged  as  a  defence,  tins  same  lunacy  commissioii  migJit  be 
of  great  value  in  examining  such  cases  and  giving  testiinojiy  upon  such 
trials,  it  having  been  provided  in  the  statute  by  ivhich  such  commission 
should  be  established,  that  the  counsel  for  the  prisoner  in  whose  behalf 
the  plea  of  insanity  is  proposed  to  be  brought  forward  should  be  com- 
pelled to  notify  such  board  of  such  proposed  pl^a.  This  board  of  experts 
shoidd  examine  the  prisoner's  mental  state,  discuss  the  question,  make 
their  conclusions,  and  should  take  zuritten  memoranda  of  such  examina- 
tion. They  tJien  should  appear  in  cornet  at  the  trial,  to  testify  as  to  the 
prisoner's  sanity,  or  irresponsibility  if  they  find  Idyn  insane.  'I  consider 
that  this  ivoidd  be  a  very  important  medico-legal  reform,  as  it  woidd 


TREATMENT    OF    INSANITY,  233 

place  rich  and  poor  on  the  same  footing  if  they  were  on  trial  for  their 
lives,  accused  of  mnrder.  Of  course,  both  the  prosecntio7i  and  defence 
could  call  in  other  experts,  as  noiv ;  but  this  hmacy  commission  report 
woidd  be  entirely  impartial,  and  the  public  woidd  know  it  to  be  so.  All 
the  factors  tending  to  the  comnnssion  of  crime  woidd  be  attcTitively 
weighed,  and  certain  penalties  woidd  not  be  ififticted  on  the  unhappy 
victims  of  diseased  imagination. 

Medical  Treatment  of  Insanity. — The  medicinal  treatment  of  in- 
sanity consists  in  removing,  as  far  as  possible,  all  functional  derange- 
ments of  the  system  by  attending  to  the  proper  performance  of  the 
functions  of  the  body.  We  must  relieve  ansemia  and  hyperaemia  of 
the  brain  so  far  as  we  are  able,  and  treat  symptoms  as  they  appear  in 
the  course  of  the  disease.  Among  the  most  valuable  remedies  for 
use  in  the  treatment  of  insanity  may  be  mentioned  opium,  hydrate  of 
chloral,  hyoscyamia,  digitalis,  ergot,  the  bromides  of  sodium,  lithium, 
and  zinc,  tincture  of  cannabis  indica,  stimulants,  and  the  use  of  pro- 
longed warm  baths,  with  cold  to  the  head,  and  the  galvanic  current 
of  electricity  to  antagonize  the  various  congestive  states  in  the  in- 
cipient stages  of  mental  diseases. 

It  is,  I  regard,  a  good  practice  in  the  therapeutics  of  insanity,  to 
give  5  to  10  grains  of  calomel  to  begin  treatment,  followed  by  salines, 
which  prepare  the  system  for  whatever  after-treatment  is  indicated. 
For  an  overworked  business  man  on  the  verge  of  insanity,  whose 
whole  system  is  probably  disordered,  in  whom  anxiety  has  caused 
loss  of  appetite  and  inability  to  sleep,  and  in  whom  the  integrity  of 
the  nervous  system  has  been  gradually  deteriorating  for  some  time, 
as  well  as  for  patients  whose  conduct  and  conversation  are  beginning 
to  attract  attention,  such  an  initial  treatment  as  I  have  described,  fol- 
lowed by  the  administration  of  30  grains  of  bromide  of  sodium  and 
30  drops  of  tincture  of  cannabis  indica  thrice  daily,  in  combination 
with  warm  baths  at  bedtime,  cold  affusions  to  the  head,  and  galvan- 
ization of  the  brain — which  latter  controls  the  cerebral  congestion — 
will  be  found  by  the  profession,  as  I  find  it  in  the  treatment  of  such 
cases,  to  be  followed  by  prompt  and  gratifying  recoveries.  Many 
such  patients  are  far  better  in  their  own  homes,  treated  by  this  plan, 
than  when  carried  away  from  home  to  an  asylum,  where,  instead  of 
rest,  which  is  one  of  my  great  therapeutical  reliances  in  early  mental 
disease,  the  patient  finds  excitement  and  is  apt  to  become  worse.  I 
do  not  at  all  underrate  the  good  work  done  at  our  asylums  by  able 
superintendents  by  the  foregoing  remarks.     Where  there  is  exhaus- 


234  PSYCHOLOGICAL    MEDICINE. 

tive  mania,  with  high  excitement  and  cerebral  anaemia,  wine  or  whis- 
key I  have  always  found  to  be  the  best  calmative  and  soporific.  I 
have  often  induced  and  kept  up  sleep  for  hours  by  the  administration 
of  half  an  ounce  or  ounce  of  fine  old  whiskey;  but  I  always  give 
the  whiskey  with  a  carminative,  so  that  the  patient  may  not  know 
what  he  or  she  is  taking. 

Food  must  be  given  regularly  and  systematically,  to  support 
strength  and  prevent  exhaustion.  A  pulse  of  150  will  come  down  to 
80  under  this  stimulative  treatment  in  exhaustive  mania,  and  a  quiet, 
refreshing  sleep  and  a  good  recovery  will  result.  Rest,  nourishment, 
positive  food, — such  as  milk,  eggs,  beefsteak,  lamb,  well-cooked  vege- 
tables, and  fruit, — sleep,  and  time,  are  all  required  for  the  cure  of 
insanity.  Restraint,  I  think,  is  grossly  abused ;  and  yet  there  are 
cases  in  which  the  camisole  (a  soft  canvas  jacket,  which  is  all  the 
restraint  ever  necessary  in  any  case)  is  temporarily  needed,  but  this 
should  never  be  at  the  option  of  a  nurse. 

Opium  has  been  called  "  the  sheet-anchor  of  the  alienist  physician." 
The  doses  of  opium  require  to  be  large,  as  the  nervous  system  is 
singularly  tolerant  to  large  doses  in  acute  mania  and  in  some  forms 
of  melancholia,  where  it  acts  specifically  by  antagonizing  the  mental 
state  of  melancholia  and  depression,  while  in  advanced  dementia  and 
general  paralysis  the  experience  of  observers  warns  us  to  be  careful 
in  its  employment.  The  dialyzed  opium,  which  is  of  the  same 
strength  as  laudanum,  and  the  bimeconate  of  morphia  are  the  best 
preparations  to  use.  With  either  of  these  we  avoid  many  of  the  un- 
pleasant effects  of  opium  in  other  forms.  I  commence  with  20 
minims  of  the  London  preparation  of  dialyzed  opium,  three  times  a 
day,  and  gradually  increase  the  dose  until  one  drachm  or  more  is 
administered,  three  times  a  day.  Guislain  recommends  large  doses, 
but  commences  with  2  grains,  which  he  increases  to  lO  or  15  grains 
as  required.  Drs.  Bucknill  and  Tuke  relate  the  case  of  a  carpenter's 
wife  who  was  affected  with  suicidal  melancholia  and  was  cured  by 
the  administration  of  large  doses  of  morphia,  and  who  was  obliged 
to  take  8  grains  of  the  muriate  of  morphia  daily.  When  taking  this 
enormous  dose  she  was  cheerful  and  enjoyed  good  health,  her  tongue 
being  clean  and  the  pulse  good,  but  when  the  dose  was  diminished 
she  again  became  depressed. 

I  had  recently  a  case  of  suicidal  melancholia  in  the  person  of  a 
young  lady  of  New  York,  who  became  insane  by  reason  of  her  lover 
leaving  her  and  marrying  another  young  lady  of  his  acquaintance. 


TREATMENT   OF    INSANITY.  235 

A  fire  broke  out  at  night,  in  her  home,  at  the  time  of  the  menstrual 
period,  and  she  ceased  menstruating  and  soon  became  maniacal. 
The  family  physician  did  all  in  his  power  for  her,  but  finally  sent  her 
to  me.  Upon  admission  she  was  entirely  incoherent  except  in  her 
desire  to  commit  suicide.  She  refused  food,  and  had  neither  eaten 
nor  slept  for  ten  days  previous  to  her  admission.  The  tongue  was 
dry,  the  teeth  covered  with  sordes,  and  she  was  fast  lapsing  into 
typho-mania.  I  fed  her  sixty-three  days,  thrice  daily,  with  the 
stomach-tube,  using  beef-tea,  milk,  milk-punch,  etc.,  and,  having 
thoroughly  evacuated  the  bowels  and  washed  out  the  kidneys  with 
a  diuretic,  I  put  her  on  a  treatment  consisting  only  of  prolonged 
warm  baths  daily,  of  half  an  hour's  duration,  at  ioo°,  and  the  hypo- 
dermic use  of  morphia.  I  commenced  with  5  minims  of  Magendie's 
solution,  thrice  daily,  and  gradually  increased  until  I  was  giving  30 
minims,  thrice  daily,  and  continued  that  dose  for  about  thirteen 
weeks.  She  gradually  improved,  and  at  the  end  of  four  months  had 
made  a  perfect  recovery.  I  used  the  tincture  of  black  hellebore  as 
an  emmenagogue,  which  restored  the  menses  to  their  normal  condi- 
tion. Two  years  have  elapsed  since  her  cure,  and  she  has  mani- 
fested no  symptoms  whatever  of  a  relapse,  and,  as  there  is  no  insanity 
in  her  family,  I  anticipate  none  in  the  future. 

The  hydrate  of  chloral  has  proved  to  be  a  very  valuable  remedy  in 
the  treatment  of  insanity,  and  also  in  delirium  tremens,  often  procur- 
ing refreshing  sleep,  when  all  preparations  of  opium  fail.  It  has  been 
shown  to  be  most  useful  in  mania  with  sleeplessness  and  restlessness, 
in  doses  of  from  15  to  30  grains,  in  combination  with  either  hyoscy- 
amus  or  morphia  and  sodium  bromide.  In  delirium  tremens  the 
doses  must  be  much  larger,  but  half-ounce  doses  of  tincture  of  digi- 
talis with  a  half  ounce  of  gin,  have  my  preference  in  this  latter  dis- 
order. As  a  therapeutic  agent,  chloral  in  doses  of  from  15  to  30 
grains  is  an  excellent  hypnotic,  causing  sound  and  refreshing  sleep, 
without  the  digestive  disturbance  which  usually  follows  the  use  of 
opium.  It  is  one  of  the  sheet-anchors  in  our  asylum.  The  great 
advantages  that  it  possesses  are,  that  it  does  not  constipate  the 
bowels,  does  not  disturb  digestion,  the  doses  do  not  require  to 
be  increased,  as  is  the  case  with  opium,  and  the  sleep  produced 
by  it  resembles  natural  sleep  more  than  that  produced  by  most 
other  narcotics.  If  pure  chloral  hydrate  be  used,  it  is  one  of  our 
most  valuable  remedies,  but  as  there  have  been  many  impure  prep- 
arations sold  in   the    market,  and  as  the   public   have   manifested 


236  PSYCHOLOGICAL    MEDICINE. 

gross  carelessness  in  using  this  dangerous — if  abused — agent,  there 
has  grown  to  be  an  unreasoning  prejudice  against  it.  Chloral 
should  always  be  freshly  prepared,  should  not  be  kept  for  any 
length  of  time  in  a  cork-stoppered  bottle,  and  only  preparations 
made  by  the  most  reliable  chemists  should  be  used,  and  finally,  ex- 
cept in  delirium  tremens,  it  is  rarely  wise  to  give  more  than  from  15 
to  30  grains  at  a  dose.  The  following  is  an  excellent  prescription  to 
combat  sleeplessness  with  maniacal  excitement,  and  produces  a  long, 
natural,  healthy  sleep,  from  which  the  patient  awakens  refreshed 
and  invigorated,  and  after  a  few  repetitions  on  successive  nights,  the 
symptoms  have  disappeared  or  have  been  greatly  relieved. 

R.  Chloral  Hydrate., ^ij. 

Sodii  Bromid.,    ..........     ^j. 

Morphine  Sulph.,         . Z^'-  H- 

Syr.  Zingib., 

Aquse,  aa .         •  f  §j- 

M.  et  ft.  Solutio.     S.  Tablespoonful  at  bedtime,  to  be  repeated  in  half  an 
hour  if  patient  is  not  asleep. 

In  the  daytime  to  produce  quiet,  the  following  pill  is  good : 

R.  Zinci  Valerianat.,         .........     3J- 

Ext.  Belladomii^, gr.  jss. 

]M.  ft.  Pill  Xo.  XXX.     Sig.  Pill  every  two  hours. 

This  is  a  very  useful  pill  in  general  paralysis  of  the  insane.  The 
following  is  also  a  ver}'  excellent  sedative  mixture  at  night : 

R.   Sodii  Bromid., 

Chloral  Hydrat.,  aa     ........  .     .^jss. 

Dialyzed  Opium  (London  Preparation),     ;         .         .         .         .     ^v. 

Fl.  Ext.  Gelsemii, ^v. 

Aquse  Dest., 

Syr.  Aurantii,  aa  .         .         .         .         .         .         .         q.  s.  ad  ^vi. 

M.    et  sig.  half  teaspoonful  in  water. 

Also  the  combination  of  30  grains  of  chloral  with  a  half  ounce  of 
fine  old  whiskey,  or  with  two  fluid  drachms  of  tincture  hyoscyamus, 
are  excellent  indeed  to  produce  refreshing  sleep. 

Chloral  having  no  influence  over  sensory  nerves,  has  no  power 
per  se  of  relieving  pain,  and  is  therefore  useless  in  that  class  of  cases 
where  opium  is  of  such  signal  service.  Chloral,  weakening  cardiac 
action,  must  not  be  given  where  we  have  any  reason  to  suspect  an 


TREATMENT    OF    INSANITY.  23/ 

enfeebled  state  of  the  heart's  action.  Its  physiological  effects  on 
the  nervous  system  are,  first  on  the  brain  and  next  on  the  spinal 
cord.  Chloral  produces  an. anaemic  condition  of  the  brain  and 
thus  causes  sleep,  by  imitating  the  natural  anatomical  arrangement 
of  that  process.  The  reflex  action  of  the  spinal  cord  is  much 
lessened,  and  the  respiratory  centre  becomes  weakened  and  eventually 
paralyzed.  The  vaso-motor  system  is  enfeebled,  but  no  special 
effects  seem  to  be  produced  on  other  nervous  structures,  unless  it  is 
considered  that  any  part  of  the  loss  of  muscular  power,  sometimes 
observed  in  those  who  have  taken  chloral  for  a  long  time,  is  due  to 
an  action  on  the  motor  nerves.  Perhaps  this  may  be  so.  As  re- 
gards the  circulatory  system,  chloral  has  a  powerful  action  on  the 
heart,  lowering  and  weakening  its  action  by  paralyzing  its  contained 
sympathetic  ganglia.  We  should  give  chloral  cautiously,  and  should 
bear  in  mind  that  strychnia  stimulates  the  respiratory  and  vaso- 
motor centres  in  the  cord,  and  thus  opposes  and  counteracts  the  most 
dangerous  tendency  of  chloral  narcosis.  Atropia  also  counteracts 
the  cardiac  and  respiratory  depression  caused  by  chloral,  as  well  as 
by  morphia,  which  constitutes  the  danger  of  their  use  in  man. 

Hyoscyamia. — The  therapeutical  effects  of  this  drug  in  acute  mania 
are  very  important  and  valuable.  Given  hypodermically  in  doses  of 
-j^Q-  of  a  grain,  it  quiets  restlessness  and  produces  sleep  with  cer- 
tainty and  efficiency.  Dr.  E.  C.  Seguin  has  very  well  summed 
up  the  experience  of  all  observers  with  reference  to  the  physiologi- 
cal and  therapeutical  effects  of  this  drug,  and  his  conclusions  as  re- 
gards its  use  in  insanity  are,  that  hyoscyamia  is  indicated  in  mania, 
restlessness,  delusions  of  persecution,  dementia  with  agitation  and 
destructiveness,  epileptic  mania,  insomnia,  rapid  action  of  the  heart, 
status  epilepticus,  chorea,  paralysis  agitans,  hysterical  spasms,  neu- 
ralgia, tremor,  etc.  That  in  mania  and  allied  states  it  produces  sleep 
as  certainl)^,  or  even  more  certainly,  than  chloral,  without  any  bad 
effect,  unless  it  be  occasional  gastric  disorder.  It  is  not  claimed  that 
its  curative  powers  are  great,  but  it  is  to  be  looked  upon,  Dr.  Seguin 
thinks,  as  a  narcotic,  often  speedier,  more  complete  and  less  objec- 
tionable than  morphia  and  chloral  hydrate.  I  doubt  very  much, 
however,  that  it  is  in  the  main  less  objectionable,  as  I  have  known 
of  one  or  two  instances  in  which  the  lio^th  of  a  grain  has  produced 
dangerous  and  almost  fatal  symptoms.  One  of  the  cases  was  the 
wife  of  a  physician,  who  administered  it  himself  and  was  much 
alarmed  at  the    effect  it  produced.       In   acute  mania,   however,   I 


238  PSYCHOLOGICAL    MEDICINE. 

should  certainly  advise  it,  as  I  have  seen  very  excellent  results  from 
it.     I  have  used  the  solution  Dr.  Seguin  advised,  namely  : 

R.  Hyoscyamias  (Merck's  crystallized),     .         .         .         .         .         •     gr- j- 

Glycerine, 

Aquae  dest.,  aa    .         .         .         .         .         .         .         .         .         .     m.  c. 

Acid.  Carbol.,     ,,........     gr.  ss. 

M.  fillra.     Sig.  mj  =  gr.  77^;^. 

Two  minims  a  moderate  dose;  four  minims  a  full  dose. 

TJie  Bromides  and  Cannabis  Indica. — One  of  the  most  charming 
combinations  to  reduce  maniacal  excitement  with  which  I  am  ac- 
quainted, and  one  which  I  use  a  great  deal,  is  a  combination  of  so- 
dium bromide,  lithium  bromide,  and  tincture  cannabis  indica, — 15 
grains  of  each  of  the  former  and  30  minims  of  the  latter  may  be 
given  three  times  a  day,  for  a  long  time  if  necessary,  with  no  ill  ef- 
fects. I  premise  the  treatment  with  a  mercurial  cathartic,  followed 
by  salines,  and  the  system  is  then  freed  from  the  often  long-retained 
excrementitious  matters,  and  is  ready  for  treatment.  Warm  baths  of 
a  half-hour's  duration  of  98°  to  100°  are  ordered  at  bedtime,  with 
cold  towels  on  the  head.  This  mixture  of  the  tincture  of  cannabis 
indica  and  the  bromides  of  sodium  and  lithium  should  be  made  at 
the  time  of  administration.  It  does  not  disturb  digestion,  it  quiets 
the  nervous  system  better,  in  most  cases,  than  chloral  or  opium,  and 
its  long-continued  use  does  not  injure  the  patient  at  all.  On  the  con- 
trary, patients  gain  health,  strength,  appetite,  and  weight.  The  dose 
can  be  increased  to  oj  of  the  bromides  (30  grains  of  each,  or  60  grains 
of  one  singly)  and  60  minims  of  tincture  of  cannabis  indica,  if  neces- 
sary, with  no  fear  of  evil  results. 

In  melancholia,  even  in  the  worst  cases,  with  suicidal  impulses,  I 
have  had  rapid  cures  from  persistent  warm-bath  treatment,  pills  of 
aloes,  and  ox-gall  and  opium  in  gradually  increasing  doses.  In  puer- 
peral insanity  we  have  a  condition  of  septicsemia  from  the  absorption 
into  the  blood  of  some  of  the  retained  products  of  conception,  and 
here  a  full  dose  of  calomel  will,  in  nine  cases  out  of  ten — if  the  in- 
sanity is  not  hereditary — start  our  patient  on  the  road  to  recovery. 
It  must  be  given  at  once,  and  be  followed  by  salines  and  appropriate 
sedatives,  and  I  have  seen,  in  a  few  days,  rapid  progress  toward  recov- 
ery. In  cases  of  hysterical  mania,  in  young  unmarried  women,  we 
often  have  at  first,  for  a  few  days,  a  wild  mania,  and  I  have  known 
some  specialists  give  a  very  unfavorable  prognosis,  which  was  not 


TREATMENT    OF    INSANITY.  239 

at  all  to  their  credit.  These  cases,  if  properly  managed,  are  very 
curable,  and  if  they  are  not  cured,  it  is  generally  owing  to  the  pa- 
tient's being  allowed  to  remain  at  home  instead  of  being  removed  to 
some  private  institution.  Fothergill's  solution  of  hydrobromic  acid, 
in  half-drachm  doses  at  bedtime  after  a  warm  bath,  with  cold  to  the 
head,  and  the  monobromide  of  camphor  (Clin's  capsules),  in  four-grain 
doses  three  times  a  day,  seclusion  of  the  patient  at  once  away  from 
her  friends,  with  a  well-trained  nurse,  who  will  in  moral  treatment 
carry  out  your  orders  to  the  letter,  will  generally  produce  marked 
results. 

In  the  worst  case  of  hysterical  mania  I  ever  saw,  I  had  my  patient 
under  the  charge  of  one  of  the  best-trained  nurses  at  my  disposal, 
and  in  a  very  few  days  she  was  down-stairs,  and  made  a  rapid  and 
complete  recovery.  This  case  was  pronounced  incurably  insane  by 
a  physician  in  charge  of  one  of  our  institutions  for  the  insane,  and 
this  assertion  was  made  in  my  presence. 

In  these  cases,  where  the  emotional  faculties  are  so  involved,  every- 
thing depends  upon  prompt  seclusion  and  rest  for  the  patient.  I 
never  treat  such  patients  at  home,  but  insist  upon  their  being  brought 
to  me  and  placed  under  experienced  nurses  in  my  private  hospital, 
and  always  see  prompt  recoveries.  Within  the  past  few  days  I  have 
seen  a  case  in  consultation  with  my  friend  Dr.  Nathan  Bozeman,  of 
this  city,  under  whose  able  care  the  lady  in  question  has  been  for 
some  time.  She  suffered  from  prolapse  of  the  uterus,  and  a  pro- 
lapsed and  imprisoned  ovary.  This  condition  had  been  skilfully 
treated  and  cured  by  Dr.  Bozeman,  but  the  patient's  health  having 
been  undermined  by  the  practice  of  self-abuse,  she  developed 
hysterical  mania.  She  shuts  herself  up,  will  not  go  out,  will  not 
allow  herself  to  be  bathed,  will  not  attempt  to  dress  or  undress 
herself,  and  the  nurse  spends  several  hours  in  performing  these  oper- 
ations. She  screams  violently  if  any  attempt  is  made  to  make 
her  walk  or  to  exert  herself  in  any  way.  She  is  in  fair  flesh,  and 
eats  and  sleeps  well.  The  mother  became  perfectly  exhausted 
by  attendance  upon  this  daughter,  and  has  been  sent  away  from 
home  to  preserve  her  own  failing  health.  The  family  is  rendered 
miserable  by  the  continued  hysterical  insanity,  and  the  first  indi- 
cation is  evidently,  in  this  case,  to  remove  the  patient  from  her 
maids  and  her  relatives  to  seclusion  and  rest,  and  put  her  under  the 
care  of  a  quiet,  determined  nurse,  who  will  follow  instructions  im- 
plicitly.    A  course  of  warm  baths,  actual  cautery  to  the  nape  of  the 


240  PSYCHOLOGICAL    MEDICINE. 

neck,  monobromide  of  camphor  in  four-grain  doses  of  Clin's  cap- 
sules three  times  daily,  and  Fothergill's  solution  of  hydrobromic  acid 
nightly,  with  the  application  of  the  constant  or  galvanic  current  of 
electricity  to  the  central  nervous  system,  will  result  in  a  speedy  and 
complete  cure  in  a  short  time.  No  anxious  and  sympathizing  rela- 
tives are  to  be  permitted  to  see  her  at  all  until  a  cure  is  well  under 
way,  or  the  good  effects  of  treatment  will  be  rendered  futile. 

I  think  it  is  only  when  these  patients  are  allowed  to  be  with  their 
friends  that  their  trouble  becomes  permanent,  or  where  the  physician 
does  not  understand  the  kind  of  case  he  has  to  deal  with.  About  two 
years  ago  I  was  called  in  consultation  to  see  a  young  New  York  lady 
with  violent  hysterical  mania,  the  result  of  emotional  excitement.  I 
found  her  perfectly  naked,  the  clothes  having  been  pulled  off  prob- 
ably as  the  result  of  a  morbid  hypersesthesia  of  the  whole  bod}^,  and 
she  was  in  a  state  of  wild  maniacal  excitement.  Upon  consultation, 
it  was  decided  to  remove  her  to  my  private  hospital,  where  she  was 
placed  under  one  of  my  best  nurses,  who  kept  her  in  strict  seclusion 
for  about  a  week,  while  the  treatment  I  have  before  detailed  was 
faithfully  carried  out.  She  made  a  good  recovery,  and  at  the  end 
of  four  months  went  home  perfectly  well,  has  never  suffered  any 
relapse,  and  has  since  married  happily,  and  enjoys  excellent  health. 

Digitalis. — The  use  of  digitalis  has  been  advocated  by  Dr.  Lock- 
hart  Robertson  and  by  Dr.  Duckworth  Williams,  his  successor  at 
Hayv/ard's  Heath,  England.  They  claim  that  digitalis  is  a  valuable 
sedative  in  both  recent  and  chronic  mania,  and  also  when  these  forms 
of  insanity  are  complicated  with  general  paresis  and  epilepsy.  The 
dose  they  employ  ranges  from  half  a  drachm  to  one  drachm  of  the 
tincture,  this  dose  being  continued  for  some  days  and  then  gradually 
decreased.  Stimulants  are  necessary  to  ward  off  the  dangerous 
exhaustion  which  accompanies  or  follows  acute  maniacal  excitement, 
and  are  contraindicated  only  where  there  is  excessive  plethora. 

Coniiun. — Conium  in  insanity,  in  doses  ranging  from  n^  xx.  to  a 
drachm  of  the  fluid  extract,  will  produce  general  muscular  relaxation, 
and,  subsequently,  quietness,  followed  by  calm  and  refreshing  sleep, 
the  whole  motor-nerve  system  being  quieted.  The  influence  of  co- 
nium is  upon  the  motor  centres  of  the  brain,  the  corpora  striata  being 
chiefly  affected.  It  quiets  irritability  and  excitement  of  the  motor 
centres  and  leaves  no  feeling  of  weakness  or  oppression  behind,  and 
is  therefore  very  valuable   in   certain   cases  of  mania.     The  pulse 


TREATMENT    OF    INSANITY.  24I 

and  temperature  are  both  reduced,  and  a  gentle  perspiration  covers 
the  whole  body  as  soon  as  the  physiological  effects  are  produced. 
Among  the  physiological  effects  may  be  noticed  dimness  and  con- 
fusion of  vision,  muscular  weakness,  slowness  of  mental  processes, 
a  feeling  of  calm  tranquillity,  lowering  of  pulse  and  temperature,  and 
finally,  refreshing  sleep,  followed  by  no  disagreeable  after-effects. 
Conia,  neutralized  by  acetic  acid  to  prevent  irritant  effects,  may  be 
used  hypodermically  in  doses  of  from  one-tenth  to  one  minim,  and 
as  it  acts  upon  the  purely  motor  centres,  and  as  morphia  acts  as  a 
sedative  to  the  sensori-motor  and  ideo-motor  centres,  a  combination 
of  the  two,  using  the  tartrate  of  morphia  in  solution  with  the  conia, 
acts  very  well  in  reducing  maniacal  excitement,  and  is  a  valuable 
remedy,  especially  in  aggressive  outbursts  of  excitement  in  the  ex- 
cited wards  of  asylums,  or  where  danger  is  threatened  in  the  home 
treatment  of  the  insane.  Caution  must  be  used  in  using  new  speci- 
mens until  their  strength  is  ascertained.  Conia  should  be  prepared 
from  the  seeds  of  the  uncultivated  plant. 

Ergot  in  the  Treatment  of  Insaitity. — It  was  proved  years  ago,  by 
the  researches  of  Brown-Sequard  and  others,  that  ergot  possessed 
the  power  of  producing  contraction  in  the  vessels  of  the  spinal  cord, 
and  it  accordingly  occurred  to  Dr.  Browne,  of  the  West  Riding  Asy- 
lum in  England,  that  it  might  possess  a  similar  control  over  the 
vessels  of  the  brain,  and  thus  be  made  to  modify  or  remove  the  ac- 
tive cerebral  congestion  which  is  an  attendant  upon  so  many  phases 
of  insanity.  Upon  a  thorough  investigation,  he  found  that  there  were 
three  varieties  of  insanity  in  which  it  was  eminently  useful,  namely, 
recurrent  mania,  chronic  mania  with  lucid  intervals,  and  lastly,  epi- 
leptic mania.  Dr.  Browne  and  other  observers,  who  have  adopted 
the  use  of  ergot  in  the  treatment  of  insanity,  have  found  that  in  the 
varieties  above  mentioned  it  was  uniformly  successful  in  reducing 
excitement,  in  shortening  the  attacks,  in  widening  the  intervals  be- 
tween them,  and  sometimes  in  preventing  their  recurrence  entirely, 
and  in  warding  off  the  dangerous  stage  of  exhaustion  by  which 
maniacal  excitement  is  so  often  succeeded.  The  way  in  which  ergot 
operates  upon  the  contractile  coats  of  the  vessels  has  been  proved 
to  be  by  its  influence  upon  the  non-striated  muscular  fibres  and  cells 
contained  in  their  coats,  thereby  exercising  a  controlling  power  over 
the  calibre  of  the  intracranial  vessels.  In  the  three  varieties  of  in- 
sanity before  referred  to, — in  recurrent  mania,  in  chronic  mania  with 
lucid  intervals,  and  in  epileptic  mania, — we  find  that  the  lesion  con- 

16 


242  PSYCHOLOGICAL    MEDICINE. 

sists  essentially  in  cerebral  hypersemia.  We  find,  although  the 
symptoms  differ  in  these  three  forms  of  mental  disease  in  which 
ergot  is  useful,  that  there  is  present  in  each  form  increased  arterial 
pulsation,  flushing  of  the  face,  suffusion  of  the  eyes,  dryness  of  the 
mouth,  and  cephalalgia.  The  disappearance  of  these  phenomena  in 
the  intervals  of  the  paroxysms  proves  that  they  are  dependent  upon 
functional  and  not  organic  changes  in  the  brain,  in  which  latter  case 
we  should  not  expect  to  find  any  marked  efficacy  from  the  use  of 
ergot,  and,  indeed,  we  often  meet  with  instances  in  which  the  con- 
trolling power  of  ergot  is,  after  a  time,  lost,  as  organic  degeneration 
gradually  follows  as  a  sequence  upon  repeated  attacks  of  mania.  In 
epileptic  mania,  it  will  be  found  that  a  combination  of  bromide  of 
sodium  with  ergot  will  materially  aid  the  action  of  the  latter  in  widen- 
ing the  intervals  between  the  fits  and  in  modifying  the  attacks  when 
they  occur.  This  combination  will  also  often  arrest  paroxysms  in 
the  incipient  stage.  The  stage  of  excitement  which  often  precedes 
and  ushers  in  the  attack,  and  which  sometimes  succeeds  it,  is 
markedly  diminished  by  the  combination  of  bromide  of  sodium  and 
ergot.  The  bromide  of  sodium  will  be  found  to  be  preferable  to  the 
bromide  of  potassium,  as  it  is  pleasanter  to  the  taste  and  causes  less 
constitutional  disturbance  than  the  latter  when  given  in  large  doses. 
Dr.  Browne  remarks  that  "  it  is  in  epileptic  mania  that  ergot  has 
been  found  pre-eminently  valuable,  in  allaying  and  abolishing  excite- 
ment and  in  conducing  to  a  healthier  tone  of  mental  action.  In  the 
outbursts  of  violent  agitation  which  precede  or  follow  a  fit  or  group 
of  fits  which  occasionally  take  their  place,  and  which  have  been  pro- 
nounced by  all  authorities  to  be  of  so  dangerous  a  character,  it  exerts 
a  prompt  and  energetic  effect.  We  may  presume  that  these  out- 
bursts are  dependent  upon  a  want  of  equilibrium  in  the  intracranial 
circulation,  primarily  disturbed  by  the  epileptic  seizure  or  condition. 
The  distension  of  the  vessels  which  succeeds  their  spasmodic  con- 
traction and  produces  coma,  subsides  so  far  as  to  allow  the  resump- 
tion of  activity  by  the  higher  centres,  but  only  in  an  irregular  and 
disturbed  way.  And  we  may  presume,  further,  that  the  soothing  and 
rectifying  effects  of  ergot  are  due  to  its  power  of  re-establishing  that 
disturbed  equilibrium.  A  thorough  trial  of  the  ergot  treatment  has 
satisfied  me  of  its  efficacy,  and  the  following  clinical  cases  will  serve 
to  illustrate  its  beneficial  action.  The  doses  of  ergot  used  in  the  fol- 
lowing cases  have  been  from  oss.  to  5j.  of  Squibb's  fluid  extract, 
three  times  a  day,  and  in  cases  in  which  ergotine  has  been  employed, 


TREATMENT   OF    INSANITY.  243 

from  5  to  10  grains  have  been  given.  No  unpleasant  effects  have 
ever  followed  even  prolonged  administration  of  the  ergot,  and  from 
our  experience  with  it,  it  would  seem  that  the  danger  of  injurious 
effects  from  its  continued  use  has  been  greatly  overrated  by  the  ma- 
jority of  the  profession. 

Dr.  Browne,  who  has  used  the  ergot  treatment  for  many  years  in 
many  hundreds  of  cases,  says:  "Indeed,  so  little  have  injurious 
effects  of  any  kind  followed  even  the  prolonged  exhibition  of  what 
might  be  termed  enormous  doses  of  ergot,  that  doubts  might  have 
arisen  as  to  whether  it  were  possible  to  produce  that  train  of  symp- 
toms described  as  ergotism,  by  means  of  the  medicinal  preparations 
of  secale  cornutum." 

Case  I. — Miss ,  with  recurrent  mania,  aged  22  years,  was  very 

noisy  and  maniacal  when  first  seen ;  was  very  incoherent  in  speech 
and  boisterous,  and  had  no  realization  of  her  condition  or  surround- 
ings. She  entertained  the  idea  that  people  were  trying  to  kill  her 
and  get  her  property.  She  destroyed  her  clothing,  broke  the  win-" 
dows,  did  much  damage  to  the  furniture,  and  imagined  that  she  saw 
snakes  and  devils  in  her  room  at  night.  She  continued  in  this  state 
for  some  time  with  no  mental  improvement.  She  commenced  by 
my  advice  to  take  the  fluid  extract  of  ergot  in  5j-  doses,  three  times 
a  day,  and  had  only  taken  a  few  doses  before  beneficial  results  were 
very  apparent.  The  excitement  subsided,  and  she  became  quiet  and 
peaceable.  The  congestion  of  the  head  and  face,  which  was  very 
marked,  has  nearly  entirely  disappeared.  Her  pulse  was  reduced 
from  145  to  90.  The  temperature  in  the  axilla  from  99y^^°  to  98°,  and 
her  tongue,  which  w^as  thickly  furred,  presents  a  normal  appearance. 

Case  II. —  Miss  M.  K.,  aged  28  years,  who  suffered  from  chronic 
mania  with  lucid  intervals.  She  was  very  violent  and  abusive,  would 
bite  and  strike  her  nurses.  Her  face  was  deeply  congested,  eyes  in- 
jected, tongue  coated  with  a  thick  white  fur,  pulse  130,  and  tempera- 
ture 99°.  Having  continued  in  this  excitable  state  for  some  days 
with  no  evidence  of  improvement,  was  ordered  5j.  of  the  fluid  ex- 
tract of  ergot,  three  times  a  day.  By  the  24th  of  June  she  began  to 
show  decided  signs  of  improvement,  and  in  place  of  being  filthy  and 
abusive  in  language  and  conduct  was  polite  and  neat  in  her  habits. 
She  also  began  to  sleep  at  night,  which  she  had  not  done  before, 
although  medicine  had  been  given  for  that  purpose.  Her  pulse  was 
lowered  to  85.     Her  temperature  decreased,  the  suffusion  of  the  eyes 


244  PSYCHOLOGICAL   MEDICINE. 

disappeared,  and  at  the  present  time  she  has  had  no  relapse  of  mani- 
acal excitement. 

Case  III. — Mr.  E.  Z.,  a  native  of  Germany,  aged  27,  was,  when  I 
first  saw  him,  suffering  from  an  attack  of  acute  mania  caused  by  over- 
work and  mental  anxiety.  Had  always  been  a  healthy  man,  and 
there  was  no  trace  of  insanity  in  the  family  history.  He  was  noisy 
and  maniacal.  He  was  ordered  a  warm  bath,  which  relieved  him  for 
about  half  an  hour,  when  he  again  became  maniacal  and  dangerous. 
Was  given  chloral  and  hyoscyamus,  and  passed  a  restless  night.  In 
the  morning  he  presented  ver}^  much  the  same  appearance  as  on  the 
preceding  evening.  Face  and  eyes  suffused  and  congested,  pulse 
100,  and  temperature  heightened;  tongue  thickly  coated,  and  mouth 
dry;  was  put  on  o]-  of  the  fluid  extract  of  ergot  three  times  a  day, 
with  chloral  and  hyoscyamus  at  night.  In  a  few  days  the  excite- 
ment began  to  subside,  and  in  less  than  two  months  he  was  com- 
paratively quiet,  and  in  fifteen  days  more  the  pulse  was  80,  the  tem- 
perature was  97/0°,  and  the  appearance  normal.  Has  remained  quiet 
up  to  the  present  time,  with  good  appetite,  sleeping  well,  and  very 
cheerful. 

Case  IV. — Aliss  S.  H.,  aged  25,  was  suffering  from  epileptic  mania. 
From  September  to  June  she  had  a  great  many  epileptic  seizures, 
which  were  preceded  and  followed  by  attacks  of  maniacal  excite- 
ment, which  rendered  her  a  dangerous  patient.  In  July  she  became 
very  noisy  and  excited,  as  was  her  habit  before  her  fits,  threat- 
ening to  kill  her  nurse  and  those  about  her.  Her  eyes  were  suf- 
fused, the  mouth  dry,  the  pulse  140,  and  the  tongue  furred.  She 
was  put  on  5j.  doses  of  fluid  extract  of  ergot,  three  times  a  day. 
After  taking  the  ergot  for  two  days  she  became  quiet,  and  the  epi- 
leptic seizure  which  followed  was  very  mild  as  compared  with  pre- 
ceding ones.  The  ergot  was  continued,  and  since  that  time  she  has 
had  no  return  of  the  maniacal  excitement.  The  fits  have  decreased 
in  frequency  and  intensity,  and  are  not  followed  as  formerly  by  any 
mental  excitement.  Her  physical  condition  has  also  been  markedly 
improved  since  she  has  taken  the  ergot.  The  pulse  is  75,  and  the 
temperature  in  the  axilla  98°,  and  she  eats  and  sleeps  well. 

Case  V. — Mr.  C,  aged  30,  was  first  seen  with  epileptic  mania.  He 
was  a  strong  muscular  man  and  had  been  subject  to  epileptic  fits 
for  some  time.  For  a  period  of  from  a  week  to  two  or  three  days 
preceding  the  fits  was  entirely  unmanageable,  and  a  very  dangerous 
man  to  deal  with.     He  was  also  accustomed  to  have  a  period  of 


TREATMENT    OF    INSANITY.  "  245 

maniacal  excitement  following  the  epileptic  seizures,  which  lasted  for 
a  variable  period,  during  which  time  his  pulse  would  range  from  lOO 
to  1 20,  and  the  face  would  be  deeply  congested.  Was  put  on  5j. 
doses  of  fluid  extract  of  ergot,  three  times  a  day,  and  this  dose  con- 
tinued for  a  period  of  two  months,  sometimes  omitting  the  medicine 
for  a  week  and  then  resuming  it.  The  fits  immediately  decreased  in 
both  frequency  and  intensity,  and  the  maniacal  excitement  entirely 
disappeared.  Pulse  and  temperature  became  normal,  and  he  made  a 
very  good  recovery.  Several  other  cases  of  mine  have  exhibited  as 
marked  improvement  under  the  ergot  treatment  as  the  foregoing,  but 
want  of  space  forbids  their  insertion. 

Last,  but  not  least,  may  be  mentioned  the  use  of  zvarm  baths,  which 
are  of  inestimable  value  in  the  treatment  of  nervous  and  mental  dis- 
eases. The  tranquillizing  effect  of  a  warm  bath  in  relieving  cerebral 
irritation  and  in  promoting  sleep,  especially  when  conjoined  with  cold 
to  the  head  at  the  same  time,  either  by  a  wet  towel  or  still  better  by 
cold  affusions,  is  often  wonderful  after  all  other  means  have  failed. 
Patients  with  excessive  maniacal  excitement,  hot  head,  dilated  pupils, 
tongue  thickly  furred,  and  a  high  temperature  in  the  axilla,  have  re- 
peatedly passed  a  comfortable  night,  after  having  remained  for  half  an 
hour  in  a  warm  bath  at  a  temperature  of  100°.  In  acute  mania,  baths 
prolonged  for  some  hours,  with  cold  to  the  head,  have  accomplished 
wonderful  results.  This,  in  connection  with  a  dose  of  chloral  and  mor- 
phia or  hyoscyamus,  will  often  suffice  for  the  relief  of  acute  mania  if 
repeated  on  successive  nights,  if  good  refreshing  sleep  can  be  induced. 
Enough  has  been  said,  however,  to  show  clearly  that  we  can  lay 
down  no  definite  plan  of  treatment  for  any  number  of  cases,  but  must 
in  every  instance,  if  we  expect  to  accomplish  a  cure,  study  the  con- 
stitution and  idiosyncrasies  of  our  patient  and  treat  him  accordingly. 
By  so  doing,  we  shall  often  have  the  satisfaction  of  seeing  apparently 
hopeless  cases  restored  to  society,  and  families  rendered  happy  which 
had  been  broken  up  by  the  visitation  of  this  fearful  disease. 

Cases  Illustrating  the  Treatment  of  Insanity. — Case  I. — Mr. , 

aged  30 ;  a  native  of  England.  When  first  seen  was  suffering  from 
acute  mania,  resulting  from  abuse  of  alcohol.  No  insane  relations. 
Said  he  left  England  to  get  rid  of  his  wife,  who  tormented  him. 
Said  he  knew  he  was  insane  when  he  left,  but  that  destitution  and 
hard  drinking  had  made  him  worse.  Toward  night  became  acutely 
maniacal  and  very  boisterous.  Tore  up  everything  within  reach,  and 
was  incoherent  and  vulgar  in  speech.     Had  no  appreciation  of  his 


246  PSYCHOLOGICAL   MEDICINE. 

condition  or  surroundings.  Quoted  almost  continually  from  Shake- 
speare and  showed  that  he  had  received  a  liberal  education.  Said  he 
burned  Spurgeon's  Tabernacle.  Eyes  suffused  and  pulse  full  and 
bounding.  Was  ordered  Vv-arm  baths  every  night,  lasting  half  an 
hour,  with  cold  affusions  to  the  head,  with  chloral  and  morphia  at 
bedtime,  the  dose  of  chloral  being  twenty  grains,  combined  with 
one-fourth  grain  of  morphia.  He  was  fed  liberally,  and  as  he  was 
always  quiet  in  the  morning  was  ordered  fluid  extract  of  ergot  in  oj- 
doses,  twice  every  afternoon  when  he  became  excited.  Under  this 
treatment  he  quieted  down  and  soon  began  to  appreciate  his  condi- 
tion and  take  an  interest  in  his  surroundings.  He  improved  gradu- 
ally and  made  a  good  recovery. 

Case  H. — Aliss ,  aged  39.    Was,  when  first  seen,  suffering  from 

melancholia,  resulting  from  syphilis.  She  was  uneasy  and  restless 
at  night  and  would  get  out  of  bed,  suspicious  of  injury  from  unseen 
persons,  who,  she  said,  were  anxious  to  kill  her.  Was  depressed, 
melancholy,  and  very  suspicious  of  all  about  her.  Imagined  her 
food  was  poisoned.  Complained  of  great  pain  in  her  head,  and  was 
pale  and  anaemic.  She  ate  and  slept  but  little.  Was  put  on  a  nour- 
ishing diet,  with  milk  punch,  and  was  given  the  bichloride  of  mer- 
cur)?-,  in  one-fifth  grain,  and  the  iodide  of  potassium,  fifteen  grains  three 
times  a  day,  with  tincture  hyoscyamus  oj.,  and  20  grains  chloral  hy- 
drate at  bedtime.  Upon  this  treatment  her  general  health  improved 
very  much.  She  began  to  eat  and  sleep,  but  would  sit  alone  all  day 
and  cry  over  imaginary  troubles.  She  improved  slowly  but  surely; 
her  delusions  gradually  disappeared;  she  became  more  cheerful  and 
happ3%  and  made  a  good  recovery.  This  is  a  very  interesting  and 
unusual  case,  as  syphilitic  insanity  is  a  very  rare  disease,  some 
authorities  claiming  that  not  more  than  one  or  two  per  cent,  of  all 
cases  present  this  complication.  The  most  frequent  form  of  syphi- 
litic insanity  is  dementia. 

The  above-mentioned  case  was  probably  the  result  of  a  simple 
irritation  of  the  central  nervous  system  due  to  the  cerebral  anaemia 
caused  by  the  syphilitic  virus.  In  another  case  the  symptoms  occur- 
ring in  a  young  gentleman  were  profound  mental  dulness,  incapacity 
to  grasp  thoughts  and  ideas,  a  desire  to  commit  suicide,  and  symp- 
toms of  compression  of  the  brain,  due,  I  presume,  to  the  thickening 
of  the  dura  mater  by  a  gummatous  deposit.  iMercury  and  large  doses 
of  the  iodide  of  potassium  effected  a  cure.  Another  case,  where  a 
clear  syphilitic  history  was  obtained,  occurred  in  a  woman  aged  29, 


TREATMENT    OF    INSANITY.  -  24/ 

a  native  of  France,  with  no  insane  relations.  This  patient's  hmbs 
were  covered  with  secondary  sores  and  the  head  was  affected  with 
gummy  tumors.  She  soon  passed  into  most  profound  dementia, 
associated  with  epileptiform  convulsions.  She  was  treated  with  a 
combination  of  mercury  and  the  iodide  of  potassium,  but  remained  a 
case  of  chronic  dementia,  defying  all  treatment.  As  I  have  before 
remarked,  as  the  results  of  the  cerebral  congestion  of  specific  origin, 
we  have  vertigo  and  dulness,  temporary  disorders  of  the  special 
senses  and  momentary  impairments  of  the  intellect,  and  these  symp- 
toms lapse  from  transitory  into  permanent  symptoms.  Persistent 
mental  dulness,  and  muscular  feebleness  exist  as  vague  undefined 
symptoms  before  the  invasion  of  actual  insanity,  with  headache  fol- 
lowed by  exaltation,  delirium,  and  mania,  which  rapidly  lapse  into 
dementia,  or  we  may  have  a  primary  dementia  without  the  stage  of 
mania. 

Case  III. — Mr. ,  aged  25  years;  single.    When  first  seen  was 

suffering  from  melancholia,  bordering  on  dementia,  caused  by  intem- 
perance and  vicious  indulgences.  He  denied  insanity  in  the  most 
positive  manner,  but  complained  of  severe  pain  at  the  back  of  his 
head  and  over  the  frontal  region.  The  faculties  of  the  mind  were 
much  enfeebled.  Would  burst  out  laughing  and  laugh  incessantly 
for  some  minutes,  and  upon  being  questioned  subsequently  had  no 
remembrance  of  doing  any  such  thing.  Had  a  delusion  that  he  had 
been  reduced  to  half  his  size  by  divine  assistance.  Saw  visions  at 
night.  Was  feeble  and  anaemic.  Had  attacks  of  mental  excitement 
about  once  a  fortnight,  in  which  the  bodily  temperature  would  be 
much  increased  and  the  eyes  suffused.  At  such  times  was  very 
homicidal  in  his  impulses,  requiring,  often,  seclusion  in  his  room. 
Was  put  on  nourishing  diet  and  tonics,  the  most  valuable  of  which 
was  my  favorite  tonic,  the  chloro-phosphide  of  arsenic  (Routh's  form- 
ula), in  ten-drop  doses,  after  each  meal,  with  fluid  extract  of  ergot  5j-, 
three  times  a  day,  and  warm  baths  at  bedtime,  when  he  could  not 
sleep.  There  was  no  perceptible  mental  improvement  for  some 
months,  but  the  general  health  was  much  improved  and  he  slept  much 
better.  The  attacks  of  cerebral  congestion  decreased  in  frequency  and 
intensity,  and  finally  ceased  altogether.  His  sleep  ceased  to  be  dis- 
turbed by  visions.  His  appetite  became  good,  his  mental  faculties 
began  to  be  restored  to  their  normal  state,  and  his  delusions  disap- 
peared. He  made  a  good  recovery,  with  no  trace  of  insane  ideas  or 
delusions,  his  conduct  for  some  months  having  been  reasonable  and 


248  PSYCHOLOGICAL   MEDICINE. 

quiet.  It  is  proper  to  mention  that  the  ergot  in  this  and  other  cases 
was  never  continued  for  more  than  two  or  three  weeks  without  sus- 
pending its  use  for  a  week  or  two,  and  using  it  in  this  way  no  inju- 
rious effects  have  ever  followed  its  employment. 

Case  IV. — Mr.  C,  aged  26  years ;  single.  Was  first  seen  suffer- 
ing from  an  attack  of  acute  mania,  the  result  of  ill-health  and  over- 
work associated  with  intemperance.  Upon  admission  was  thin  and 
anemic  and  was  rambling  and  incoherent  in  speech.  Said  he  was 
married  to  the  Queen  of  Heaven.  Was  sleepless ;  ate  but  little  and 
was  very  destructive  in  his  impulses,  tearing  up  clothing,  etc.  The 
eyes  were  injected  and  the  pupils  widely  dilated.  Was  given  bromide 
of  sodium  in  fifteen-grain  doses  three  times  a  day,  which  was  in- 
creased to  twenty  grains,  with  full  doses  of  chloral  and  tincture  hyos- 
cyamus  at  bedtime.  Full  nourishing  diet.  Soon  became  quiet  and 
polite,  and  with  the  increased  health  and  strength  his  mind  became 
normal  and  his  delusions  disappeared. 

Case  V. — Mr.  F.,  aged  23  years;  single.  Was  suffering  from  an 
attack  of  recurrent  mania  when  first  seen.  He  was  depressed  and 
sullen  and  would  not  answer  questions.  His  tongue  was  thickly 
furred  and  the  bowels  constipated.  He  was  ordered  a  laxative  and 
warm  baths  at  bedtime,  as  he  said  he  did  not  sleep  well.  In  a  few 
days  the  eyes  became  injected,  the  pupils  dilated,  head  hot  and  speech 
wild  and  incoherent  and  movements  restless  and  excited.  Said  he 
had  a  worm  inside  him  that  was  eating  him  up.  Thought  the  food  was 
poisoned  and  refused  to  eat.  Was  ordered  warm  baths,  fluid  extract 
ergot,  in  one-drachm  doses,  three  times  a  day,  and  chloral,  20  grains, 
combined  with  one-quarter  grain  of  morphia,  at  bedtime.  In  a  few 
days  the  cerebral  congestion  abated,  and  he  went  on  until  the  next 
month  when  he  had  a  recurrence  of  the  mania,  which  was  preceded 
a  few  hours,  as  before,  by  melancholia  and  constipation.  The  same 
treatment  was  employed  and  the  maniacal  attack  lasted  but  twenty- 
four  hours.  The  ergot  was  continued  through  the  lucid  interval,  and 
was  discontinued  at  the  end  of  four  weeks,  as  he  had  no  symptoms 
of  another  attack.  He  remained  w^ell  until  January,  1875,  when  he 
had  a  recurrence  of  the  mania,  which  was  treated  as  before,  with 
the  addition  of  bromide  of  sodium,  in  20-grain  doses,  three  times  a 
day.  This  was  his  last  attack.  He  improved  steadily  in  health  and 
strength ;  his  delusions  disappeared,  he  began  to  show  an  interest  in 
his  surroundings,  and  made  a  good  recovery. 

Case  VI. — Miss  N.,  aged  20  years ;  single.    Was  suffering  from  an 


TREATMENT    OF    INSANITY,  249 

attack  of  acute  mania  when  first  seen.  Previous  to  this  attack  she  had 
been  a  remarkably  well-behaved  and  quiet  girl,  and  had  been  rea- 
sonably healthy.  She  was  acutely  maniacal,  with  rapidly  changing 
delusions.  Saw  devils,  snakes,  and  angels,  in  rapid  succession,  and 
said  the  Virgin  Mary  visited  her  every  night  in  her  room.  Pulse 
rapid,  tongue  thickly  furred,  bowels  constipated,  and  eyes  injected, 
with  the  pupils  dilated.  Destroyed  everything  within  her  reach. 
The  display  of  muscular  strength  which  she  exhibited  was  something 
remarkable.  She  was  put  in  warm  baths,  with  chloral  and  morphia 
internally  at  bedtime,  but  did  not  sleep.  Refused  food  and  was  so 
violent  that  the  attempt  to  feed  her  artificially  was  for  the  time 
abandoned.  None  of  the  usual  remedies  seemed  to  quiet  her  in  the 
least,  and  she  seemed  likely  to  die  of  exhaustion  from  the  violence  of 
her  mania,  when  she  was  ordered  the  monobromide  of  camphor 
(Clin's  capsules,  made  in  Paris),  in  doses  of  four  grains  three  times  a 
day.  This  remedy  acted  charmingly.  After  the  third  day's  trial  the 
temperature  in  the  axilla  became  reduced  from  102°  to  99^°.  The 
pulse  was  reduced  in  frequency  and  the  suffusion  of  the  eyes  dis- 
appeared. The  pupils  were  reduced  to  their  normal  size.  She  be- 
gan to  sleep  and  eat,  and  at  the  end  of  ten  days  was  quiet  and  tran- 
quil. The  doses  were  reduced  to  two  grains  three  times  a  day  as  the 
mania  decreased,  and  were  continued  for  about  a  month.  The 
mental  faculties  improved,  the  appetite  returned  to  its  normal  condi- 
tion, she  began  to  take  exercise  in  the  open  air,  and  finally  made  a 
good  recovery.  From  my  experience  with  the  use  of  the  monobro- 
mide of  camphor  (Dr.  Clin's  imported  preparation),  I  believe  it  to  be 
an  excellent  sedative  of  the  cerebral  system,  and  at  times  a  decided 
hypnotic.  In  epilepsy  and  hysterical  mania  it  has  acted  as  a  nervous 
sedative  and  antispasmodic,  with  good  effects,  in  doses  of  from  two 
to  four  grains,  three  times  a  day. 

Case  VII. — Miss  G.,  aged  1 8  years;  single.  Was  seen  suffering 
from  acute  mania.  Was  noisy  and  boisterous  and  a  dangerous  pa- 
tient. Was  homicidal  in  her  impulses.  The  pupils  were  widely 
dilated ;  head  hot,  and  she  complained  of  intense  pain  in  frontal  region 
at  times.  Was  incoherent  in  speech  and  had  no  appreciation  of  her 
condition  and  surroundings.  Was  thin,  and  ate  and  slept  but  little.  Was 
ordered  warm  baths  at  a  temperature  of  ioo°  every  afternoon,  and 
cold  affusions  to  the  head,  at  the  same  time  with  chloral  and  mor- 
phia at  bedtime.  She  was  also  given  thirty  grains  of  the  bromide 
of  sodium  twice  a  day.     In  a  short  time  she  became  quiet  and  re- 


250  PSYCHOLOGICAL   MEDICINE. 

mained  so  for  three  months,  during  which  time  she  had  various  delu- 
sions and  retained  her  homicidal  impulses.  At  the  end  of  that  time 
she  became  acutely  maniacal,  and  was  put  on  fluid  extract  of  ergot 
and  warm  baths,  with  cold  applications  to  the  head,  and  chloral  and 
hyoscyamus,  in  full  doses,  at  bedtime.  In  a  week  she  began  to  im- 
prove, and  her  appetite,  which  had  been  poor  since  her  admission, 
became  good.  She  realized  her  situation  and  thanked  the  doctor 
and  her  nurses  for  their  care  of  her.  She  no  longer  wished  to  injure 
those  about  her  and  continued  to  improve  daily.  Her  insane  delu- 
sions totally  disappeared,  and  she  has  made  an  excellent  recovery 
and  has  had  no  relapse. 

Case  VIII. — Miss  K.,  aged  24  j^ears;  single.  When  first  seen  was 
suffering  from  suicidal  melancholia,  and  had  a  great  many  delusions 
of  fear  and  persecution.  Said  that  everybody  wanted  to  kill  her,  and 
so  she  had  better  kill  herself  Got  very  angry  at  trifles,  and  swore, 
and  struck  those  about  her.  Had  no  appreciation  of  her  mental 
condition.  Was  put  on  a  full  nourishing  diet,  with  dialyzed  opium 
(London  preparation,  same  strength  as  laudanum)  in  gradually  in- 
creasing doses,  and  warm  baths,  with  bromide  of  sodium  (30  grains) 
at  bedtime.  She  was  kept  on  this  treatment  for  some  weeks,  with 
gradual  improvement.  The  dialyzed  opium  was  carried  to  the  extent 
of  60  minims,  three  times  a  day,  with  excellent  effects.  The  appe- 
tite was  stimulated,  and  she  became  cheerful  and  realized  her  condi- 
tion and  surroundings.  She  slept  well,  and  the  desire  to  commit 
suicide  disappeared.  The  amount  of  opium  was  gradually  decreased 
as  the  mental  condition  improved,  and  was  finally  withdrawn  alto- 
gether.    She  made  a  good  recovery. 

Case  IX. — Miss  M.,  aged  24  years  ;  single.  AVas  first  seen  suffer- 
ing from  acute  mania.  Was  very  much  excited,  eyes  injected,  and 
pupils  widely  dilated.  Head  hot  and  face  flushed.  Had  slept  none 
for  a  week,  and  had  eaten  nothing  for  the  same  length  of  time.  Was 
given  a  warm  bath,  and  milk-punch,  and,  at  bedtime,  20  grains  of 
chloral,  with  one-fourth  grain  of  morphia.  Slept  part  of  the  night. 
The  next  day  she  was  maniacal,  and  imagined  all  her  food  was  poi- 
soned. Was  fed  on  milk-punch,  and  had  a  prolonged  warm  bath, 
with  the  chloral  and  morphia  repeated  at  bedtime.  She  slept  bet- 
ter than  on  the  preceding  night.  During  the  next  three  weeks  the 
same  treatment  was  persisted  in,  resulting  in  gradual  improvement. 
She  retained  the  delusion  respecting  the  food.  She  had  new  attacks 
of  mania,  recurring  about  once  in  three  days,  at  night,  when  she 


^         TREATMENT    OF    INSANITY.  25 1 

would  see  visions  of  angels,  etc.  She  was  put  on  fluid  extract  of 
ergot,  60  minims,  thrice  daily,  with  decided  improvement.  She  im- 
proved rapidly.  Began  to  eat  all  that  was  given  her,  slept  quietly 
all  night,  and  soon  made  an  excellent  recovery. 

Case  X. — Mr.  B.,  aged  36 ;  occupation,  architect.  When  first  seen 
was  suffering  from  acute  mania,  which  followed  repeated  attacks  of 
delirium  tremens.  Nervous  system  very  much  broken  down.  Thin 
and  anemic,  with  poor  appetite.  Slept  but  little.  Was  put  on  a 
nourishing  diet  and  pills  of  phosphate  of  zinc  with  the  extract  of  nux 
vomica  (nine-tenths  of  a  grain  of  the  former  and  one-fourth  grain  of 
the  latter),  thrice  daily.  Also,  pepsin  and  bismuth  before  meals,  as 
the  digestion  was  impaired.  He  had  warm  baths,  and  chloral  and 
hyoscyamus  in  full  doses  at  bedtime.  He  soon  began  to  improve. 
The  hallucinations  of  sight  and  hearing  with  which  he  had  been 
affected  disappeared.  The  general  health  improved,  and  in  two 
months  from  the  time  when  he  was  first  seen,  made  a  good  recovery, 
having  gained  markedly  in  flesh. 

Case  XL — Mr.  P.,  aged  16,  was  seen  in  a  state  of  great  exhaustion 
from  acute  mania,  threatening  death.  Tongue  and  lips  dry  and 
black,  eyes  deeply  injected  and  pupils  widely  dilated.  Had  not  eaten 
nor  slept  for  over  a  fortnight.  Was  acutely  maniacal,  although  so 
much  exhausted.  Was  put  to  bed  and  given  a  full  dose  of  brandy, 
which  was  followed  by  a  dose  of  chloral  and  morphia.  He  slept 
part  of  the  night.  The  next  day  he  was  freely  stimulated  and  fed 
with  beef-essence,  and  eggs  beaten  up  raw.  This  treatment  was  fol- 
lowed up  for  a  week,  with  chloral  and  morphia  at  bedtime,  with  the 
happiest  results.  He  became  quiet  and  slept  well.  The  sordes  dis- 
appeared from  the  teeth  and  tongue,  and  he  asked  to  see  his  mother, 
and  recognized  her.  Talked  incoherently  for  some  time,  but  real- 
ized his  condition  and  surroundings  in  his  lucid  intervals.  Was  put 
on  phosphide  of  zinc,  in  one-tenth  grain  doses,  three  times  a  day, 
with  good  results.  The  appetite  increased,  the  mental  faculties  im- 
proved, and  he  continued  to  convalesce,  and  made  a  good  recovery. 
The  cause  of  the  insanity  was  thought  to  be  the  immoderate  use  of 
tobacco,  which  acted  very  injuriously  upon  a  defective  organization 
and  weakened  nervous  system,  inherited  from  his  father,  who  was  an 
intemperate  man  and  died  of  phthisis. 

Many  more  cases  might  be  noted,  but  want  of  space  forbids  their 
insertion.  Phosphorus  and  the  chloro-phosphide  of  arsenic  (Routh's 
formula,  the  imported  preparation)  have  been  largely  used  by  us  in  the 


252  PSYCHOLOGICAL   MEDICINE. 

convalescence  in  mental  disorders,  and  also  cod-liver  oil  and  quinine 
in  2-grain  doses.  The  foregoing  cases  illustrate  the  necessity  of 
repressing  cerebral  excitement ;  inducing  sleep,  by  which  the  brain- 
cells  are  renovated ;  and  restoring  the  functions  of  the  body,  which 
are  often  disordered  in  mental  disease.  In  addition  to  these  meas- 
ures, if  we  provide  cheerful  surroundings,  new  objects  of  attention 
and  interest,  and  can  induce  a  healthy  train  of  thought,  we  shall 
very  often  have  the  pleasure  of  seeing  our  patients  make  a  good 
recovery. 

The  Vaj'ieties  of  Insanity  in  Relation  to  Treatment. — The  general 
practitioner  should  bear  in  mind  that  with  him  rests  a  great  respon- 
sibility, as  it  is  during  the  early  stages  of  insanity  that  he,  if  intelli- 
gently informed  as  to  mental  disorders,  may  successfully  check  their 
progress  or  ward  them  off.  He  should,  therefore,  carefully  study 
and  recognize  every  deviation  from  the  healthy  mental  standard  of 
disease,  indicating  the  necessity  for  medical  treatment  and  advice, 
and  it  is  to  be  hoped  that,  in  the  near  future,  no  medical  college 
shall  be  granted  a  charter  which  does  not  provide  a  chair  for  instruc- 
tion in  mental  diseases,  with  especial  reference  to  their  early  diag- 
nosis, and  to  the  therapeutics  of  insanity  by  practical  alienists.  Of 
what  immense  advantage  to  the  profession  would  it  have  been  had 
they  been  able,  during  the  past  twenty-five  years,  to  have  had  the 
theory  and  practice  of  psychiatry  expounded  to  them,  both  in  col- 
leges and  in  the  wards  of  our  insane  hospitals,  by  such  men  as  the  late 
Dr.  Ray,  Dr.  Kirkbride,  Dr.  Pliny  Earle,  and  many  others,  who  are 
sound,  practical  psychologists  and  alienists.  How  can  a  man  igno- 
rant of  the  first  principles  of  psychological  medicine  intelligently 
sign  a  certificate  of  insanity  consigning  a  human  being,  perhaps  for 
life,  to  an  insane  asylum  ?  There  is  no  disorder  of  mind  without 
disorder  of  brain,  and  it  is  the  great  medical  evil  of  the  day  that  at 
present,  in  our  medical  colleges,  very  little  attention  has  as  yet  been 
paid  to  the  study  and  treatment  of  such  disorders.  The  profession 
and  medical  students  have  a  right  to  demand  that,  as  they  as  medi- 
cal men  will  be  required  by  the  legislatures  of  the  respective  States 
in  which  they  practice  medicine  to  sign  certificates  of  insanit}',  and 
that  as  to  their  care  will  be  committed  many  in  the  early,  curable 
stages  of  insanity,  they  shall  be  taught  in  medical  colleges,  by  a  spe- 
cial professor : 

I.  The  healthy  functions  of  a  healthy  brain;  the  structures  which 
form  the  cerebrum ;  the  nerve-cells  and  nerve-fibres ;  the  neuroglia, 


TREATMENT   OF    INSANITY.  253 

in  which  the  cells  are  imbedded,  and  the  bloodvessels  and  lymphatics. 
The  nerve- cells  are  gathered  together  in  the  great  nerve-centres, 
and,  as  an  electrical  battery  sends  the  current  of  electricity  along  the 
connecting  cord  to  the  electrode,  so,  in  like  manner,  by  means  of  the 
nerve-fibre,  does  the  nerve-cell  communicate  with  the  organs  of  spe- 
cial sense,  with  the  sensory  ganglia  and  spinal  cord,  with  each  other, 
and,  finally,  with  the  nerve-cells  of  the  convolutions  of  the  other 
hemisphere.  The  phenomena  of  healthy  mind  include  sensation, 
feeling,  and  consciousness.  These  the  student  may  study  subject- 
ively, and  then  he  will  be  prepared  to  be  taught  objectively, 

2.  The  abnormal  functioning  of  an  unhealthy,  diseased  brain.  Re- 
specting the  subjective  study,  the  remarks  of  the  great  philosopher 
Seneca  are  very  appropriate,  where  he  says  :  ''  What  does  it  profit  us 
to  master  our  appetites  without  understanding  the  when,  the  what, 
the  how,  and  other  circumstances  of  our  proceedings  ?  For  it  is  one 
thing  to  know  the  rate  and  dignity  of  things  and  another  to  know 
the  little  nicks  and  springs  of  action."  Seneca  also  truly  said : 
"  Philosophy  is  the  health  of  the  mind.  Let  us  look  to  that  health 
first,"  etc.  Of  such  a  one  (a  philosopher)  he  says  :  "  He  studies  to 
fill  rather  his  mind  than  his  coffers.  His  life  is  ordinate,  fearless, 
equal,  secure.  He  stands  firm  in  all  extremities,  and  bears  the  lot 
of  his  humanity  with  a  divine  temper."  I  fancy  that  a  thorough 
study  of  this  great  philosopher  might  not  be  utterly  inappropriate  to 
those  who  desire  to  understand  and  master  the  hidden  springs  of 
human  action,  and  that  an  acquiescence  in  his  teachings  might,  by 
teaching  us  how  to  best  master  our  hopes  and  fears,  how  to  tune  our 
affections  and  keep  ourselves  constant  to  ourselves,  how  to  measure 
our  appetites  so  as  to  know  when  we  have  had  enough,  and  by 
making  us  understand  that  "  the  good  of  life  does  not  consist  in  the 
length  or  space,  but  in  the  use  of  it,"  operate  in  the  direction  of  the 
prevention  of  much  insanity.  Seneca  was  a  wise  psychologist  when 
he  said  :  "  Let  us  rather  study  how  to  deliver  ourselves  from  sadness, 
fear,  and  the  burden  of  all  our  secret  lusts.  Our  duty  is  the  cure  of 
the  mind  rather  than  the  delight  of  it ;  but  we  have  only  the  words 
of  wisdom  without  the  works,  and  turn  philosophy  into  a  pleasure 
that  was  given  for  a  remedy."  Could  the  masses  be  taught  to  gov- 
ern their  hopes  and  fears,  their  anxiety  of  thought  and  their  per- 
petual disquiet,  there  would  soon  cease  to  be  an  increase  of  insanity 
disproportionate  to  the  increase  of  population,  as  now  exists,  and 
observance  of  hygienic  laws  would  soon  become  a  matter  of  habit. 


254  PSYCHOLOGICAL   MEDICINE. 

Respecting  the  phenomena  of  diseased  mind  or  unhealthy  brain 
function,  the  student  will  learn  that  there  may  be  impairment  or  ces- 
sation of  nerve-function,  and  that  this  is  generally  ushered  in  by 
sleeplessness  and  marked  nervous  exhaustion ;  that  there  is  a  pro- 
dromic  period,  marked  by  distinct  psychic  signs,  during  which  period 
there  is  a  defective  generation  and  supply  of  nerve-force.  He  will 
be  taught  clinically  that  there  is  often  an  initiatory  stage  of  depres- 
sion before  a  maniacal  attack.  He  will  also  be  taught  that  there  is 
very  often  cerebral  hyperasmia,  evinced  by  a  hot  head,  sleeplessness, 
cephalalgia,  flushed  face,  and  injected  conjunctiva.  A  person  may  not 
sleep  or  even  eat  for  some  days  while  in  this  condition.  Clinically  he 
will  see,  in  the  wards  of  an  insane  hospital,  the  gloom  oi  melancholia  ; 
the  delirium,  violence,  excitement,  and  incoherence  o'i mania;  and  the 
silly,  vacant,  meaningless  behavior  of  the  patient  with  dementia.  The 
melancholiac  may  evince  much  distress,  will  be  full  of  gloomy  fore- 
bodings, will  have  a  great  weariness  of  life,  and  very  likely  will  have 
attempted  self-destruction.  He  will  be  told  that  the  patient's  bowels 
are  torpid,  and  that  very  likely  there  is  lithaemia.  The  treatment 
very  likely  has  begun  with  an  aloetic  and  mercurial  cathartic,  and 
this  may  have  been  followed  by  a  course  of  warm  baths  and  opiates, 
and  in  a  few  months  the  insanity,  if  not  hereditary,  will  have  yielded 
to  this  treatment,  and  the  patient  have  returned  home  cured. 

The  maniacal  patient  will  be  violent  in  conduct,  abusive  in  lan- 
guage, and  angry  and  wilful,  perhaps  very  obstinate.  There  will  be 
great  restlessness  and  delusions,  and  perhaps  he  may  have  been 
homicidal.  The  head  may  be  hot  and  the  conjunctiva  suffused,  and 
the  muscular  movement  violent.  Or  the  head  may  be  cool  and  the 
pulse  small  and  quick.  In  such  a  case  a  mercurial  cathartic  may 
have  been  used  to  prepare  the  system  for  further  treatment,  which 
may  be  ether  5j.;  tincture  opii  Tt^.  xxx.  to  xl.,  ter  die.  Under  the  in- 
fluence of  this  treatment,  the  patient  may  have  improved  rapidly, 
with  good  food  and  plenty  of  fresh  air  and  occupation.  In  this  case, 
also,  very  likely  the  prolonged  warm  bath  with  cold  to  the  head  for 
half  an  hour,  has  been  frequently  used.  The  case  of  demcjitia  with 
a  weak  mind,  and  who  has  been  foolish  and  irritable,  and  inattentive 
to  the  calls  of  nature,  and  mischievous,  and  whose  memory  seems 
quite  gone,  has  been  treated  by  tonics,  and  perhaps  the  chloro-phos- 
phide  of  arsenic  in  5-minim  doses  ter  die,  and  gradually  decreased, 
and  perhaps  has  had  croton  oil  rubbed  on  the  shaven  scalp.     Under 


TREATMENT    OF    INSANITY.  255 

this  treatment  she  may  have  made  a  good  recovery,  particularly  if 
the  dementia  has  followed  some  exhausting  and  prostrating  disease. 

The  student  will  be  told  that  in  sthenic  mania,  the  continued  warm 
bath  of  from  half  to  one  hour  or  more,  with  cold  to  the  head,  the  ad- 
ministration of  a  mercurial  cathartic,  the  induction  of  sleep,  occupation 
and  exercise  in  the  fresh  air,  and  time,  will  often  effect  a  cure  in  appar- 
ently very  unpromising  cases ;  while  in  asthenic  cases,  stimulants 
are  well  borne,  and  are  necessary  with  tonic  treatment.  He  will  learn 
in  the  wards  of  an  insane  hospital,  what  is  perhaps  new  to  him,  that 
opium  is  the  physiological  antagonist  to  the  psychical  states  of  gloom 
and  despair,  with  suicidal  tendencies,  seen  in  melancholia.  He  will 
also  learn  that  the  lucid  interval  of  chronic  mania  is  very  far  from 
the  recovery  it  sometimes  appears  to  be,  and  that  the  case  of  reason- 
ing mania,  who  has  committed  some  crime,  exhibits  not  the  slightest 
remorse,  such  as  a  sane  person  would  suffer  from.  That  such  a  pa- 
tient is  very  plausible,  cruel,  treacherous,  lies  on  all  occasions,  when- 
ever it  serves  his  or  her  purpose,  and  always  justifies  the  acts  performed 
and  considers  them  quite  praiseworthy.  The  intellect  seems  quite 
acute,  and  the  patient  probably  roundly  abuses  those  who  are  work- 
ing for  a  cure,  and  is  considered  as  the  mischief-maker  of  the  ward 
of  which  he  or  she  is  an  inmate.  No  treatment  will  avail  in  this 
case,  as  the  student  of  psychiatry  will  be  told  that  there  is  here  a 
congenitally  diseased  brain,  with  a  total  absence  of  all  moral  sense — a 
true  moral  imbecility.  The  feelings  and  moral  sentiments  have  been 
affected  in  this  case,  the  emotional  insanity  finally  taking  on  a  de- 
structive character.  This  patient  will  have  been  the  scourge  of  his 
or  her  family  from  childhood.  This  is  a  case  of  moral  or  emotional 
insanity  proper,  with  an  exalted  emotional  condition.  The  affec- 
tions and  dispositions  are  perverted.  Dementia  may  appear  as  the 
patient  advances  in  years,  and  the  insane  hospital  is  the  only  safe 
and  proper  place  for  such  a  one.  Of  the  various  forms  of  insanity 
in  relation  to  treatment,  we  have  shown  the  student  the  clinical 
phases  of  mania,  melancholia,  dementia,  and  moral  insanity,  or  rea- 
soning mania. 

General  Paralysis  of  tJie  Insane. — We  shall  see  the  general  para- 
lytic, or  case  oi paralytic  dementia,  exhibiting  a  general  and  progres- 
sive loss  of  co-ordinating  power  over  his  muscles  (we  shall  rarely 
see  a  female  with  this  disease),  and  exhibiting  clinically  a  mental  fee- 
bleness bordering  on  dementia.  The  poor  fellow,  who  is  doomed, 
probably,  for  this  is  one  of  the  most  incurable  forms  of  insanity,  will 


256  PSYCHOLOGICAL    MEDICINE. 

tell  US  that  he  feels  in  perfect  health,  is  worth  millions,  and  has  other 
delusions  of  grandeur.  As  he  is  talking,  we  notice  the  tremor  of 
his  lips  and  tongue,  and  as  he  walks  we  see  that  his  gait  is  very  un- 
certain. As  we  look  closely  at  him,  we  see  that  his  pupils  are  un- 
equal, but  this  condition  may  be  present  or  absent.  The  motor,  sen- 
sory and  psychical  functions  generally  are  performed  sluggishly,  and 
paralysis  of  the  sphincters  comes  on  and  the  patient  dies  of  exhaus- 
tion. The  patient  may  have  had  maniacal  attacks  during  his  illness. 
If  he  is  inclined  to  be  excitable  and  restless,  we  may  give  him  a  com- 
bination of  chloral,  sodium  bromide,  and  morphia  at  night,  with  a 
pill  every  two  hours  of  valerianate  of  zinc  and  belladonna,  and  cold 
baths  with  central  galvanization.  This  may  relieve  symptoms  very 
markedly,  and  in  the  early  stages  may  possibly  do  more  than  this,  but 
the  prognosis  is  very  gloomy  indeed.  The  evening  temperature  is 
always  higher  than  the  morning.  We  may  diagnose  this  disease  by 
the  thermometer,  as  the  rise  will  be  seldom  less  than  l°,  and  in  de- 
structive cases  may  be  as  high  as  2°. 

Epileptic  Insanity. — We  shall  find  this  patient  presenting  a  history 
like  the  following :  There  will  be  a  maniacal  attack  accompanying 
the  fit,  lasting  for  a  few  hours,  and  it  may  appear  again  after  the  fit 
any  time  within  a  few  days.  There  are  likely  to  be  instantaneous 
acts  of  violence  committed  by  this  patient,  and  especially  in  non-con- 
vulsive cases.  The  higher  the  epileptic  excitement  the  less  likely 
is  the  patient  to  be  dangerous,  as  the  morbid  impulses  towards  hom- 
icide more  frequently  accompany  the  milder  attacks,  where  the 
patient  is  apparently  very  mild  and  tractable.  There  is  an  uncon- 
sciousness of  acts  performed,  as  there  is  unconsciousness  in  all  true 
epilepsy.  There  is  vertigo,  injection  of  the  conjunctiva,  dilatation 
or  alternate  dilatation  and  contraction  of  the  pupils,  and  a  slow  res- 
piration. The  temperature  may  be  below  the  normal,  except  about 
the  time  of  the  paroxysm,  when  it  becomes  heightened,  as  does  the 
pulse.  There  is,  sometimes,  a  heavy  drunken  sleep  before  the  re- 
turn to  sanity  and  consciousness. 

It  is  extremely  important,  from  a  medico-legal  standpoint,  to  re- 
member the  violence  and  the  unconscious  states  of  epileptics,  and 
the  existence  of  temporary  mental  disorders  occurring  after  epileptic 
paroxysms.  The  mental  condition  of  epileptics  has  received  too  little 
attention.  The  best  treatment  in  these  cases  has  seemed  to  us  to  be 
a  combination  of  sodium  bromide,  30  grains,  and  fluid  extract  of  er- 


TREATMENT    OF    INSANITY,  25/ 

got  5ss.  to  5j.  ter  die,  occasionally  intermitting  the  treatment,  with 
plenty  of  outdoor  exercise  and  carefully  regulated  diet. 

Insanity  of  Pubescence. — This  form  of  mental  disease  resembles  in 
its  clinical  features  moral  or  emotional  insanity  proper,  and  rarely 
comes  under  treatment,  as  the  parents  fail  to  recognize  the  case  as 
one  of  insanity.  The  great  diagnostic  mark  is  here  the  abnormal 
mental  condition  occurring  during  the  evolution  of  the  reproductive 
system  at  the  time  of  pubescence.  The  treatment  of  the  case  if  for- 
tunately recognized  as  disease  instead  of  depravity,  should  be  mainly 
moral,  with  quiet  and  rest.* 

Insanity  from  Masturbation. — These  cases  exhibit,  clinically,  delu- 
sions of  fear  and  persecution,  while  the  manner  and  conversation  is 
pretty  normal.  The  extremities  are  apt  to  have  a  cool,  clammy  feel. 
Such  cases  are  sulky  and  disagreeable  in  the  wards  of  an  asylum, 
and  we  shall  notice  an  evasive  look  in  the  face,  and  a  failure  of  the 
patient  to  look  you  squarely  in  the  eyes,  and  that  he  seems  afraid. 
The  prognosis  is  very  gloomy.  They  are  apt  to  be  incurable  cases. 
A  combination  of  quinia,  i  grain,  strychnia,  eV  g^sii^>  with  the  com- 
pound tincture  of  gentian,  ter  die,  is  the  best  tonic.  These  cases  tend 
to  become  demented. 

NympJiomania  and  Hysterical  Insanity. — These  forms  of  insanity 
present  every  phase  of  mental  alienation,  and  are  best  treated  with 
central  galvanization.  The  monobromide  of  camphor  in  4-grain 
capsules  ter  die  (Clin's  capsules)  and  arsenic.  The  application  of 
the  cautery  to  the  nape  of  the  neck  occasionally  is  good  practice. 
Also,  Fothergill's  solution  of  hydrobromic  acid,  15  to  30  minims, 
after  a  warm  bath,  at  bedtime,  with  cold  to  the  head. 

Insanity  of  Gestation  or  Pregnancy. — This  is  a  rare  disease.  If 
a  woman  is  predisposed  to  insanity,  she  may  become  so  in  her  first 
pregnancy,  but  I  think  it  rarely  occurs  without  such  predisposition. 
There  may  or  may  not  be  recovery  at  parturition,  and  the  patient 
may  pass  into  chronic  insanity.  The  psychical  state  is  generally 
that  of  melancholia. 

*  We  have  a  case  of  this  form  of  mental  disease  at  present  under  our  care  in  a  girl  of 
sixteen  years,  with  marked  excitability  at  each  menstrual  epoch  and  decided  erotic  ten- 
dencies. She  will  be  very  affectionate  towards  her  mother,  and  then,  with  no  provocation, 
strike  her  violently.  She  also  is  very  profane  at  times,  although  she  has  been  brought 
up  in  the  most  careful  manner.  We  anticipate  a  speedy  cure.  At  the  time  of  writing 
this  we  have  just  been  consulted  relative  to  another  case  of  a  girl  fifteen  years  of  age, 
with  pubescent  insanity.  Overstudy  and  grief  at  the  loss  of  a  brother,  together  with  the 
excitement  attendant  upon  the  critical  period,  induced  the  attack. 

17 


258  PSYCHOLOGICAL   MEDICINE. 

Puerperal  Insanity. — This  form  of  mental  disease  occurs  after  par- 
turition, generally,  we  think,  owing  to  the  absorption  into  the  system 
of  some  of  the  retained  products  of  conception,  and  therefore,  on  this 
principle,  we  have  been  accustomed  to  administer  promptly  a  strong 
mercurial  cathartic,  20  grains  of  calomel,  followed  by  salines  and  min- 
eral acids,  and  a  course  of  hot  baths,  with  cold  to  the  head,  and  perfect 
rest  and  quiet.  Acute  mania  and  melancholia  are  the  most  frequent 
types  of  this  insanity.  The  lochia  are  diminished  or  suppressed,  and 
the  milk  sometimes.  Among  the  exciting  causes,  Bucknill  and  Tuke 
rank  mental  shock  of  any  kind,  distress  of  mind,  especially  in  unmar- 
ried women,  a  tedious  exhausting  labor,  flooding  and  the  use  of  the 
lancet  for  puerperal  convulsions.  Hereditary  predisposition  is  of 
course,  in  many  cases,  a  prominent  feature.  The  prognosis  is  very 
favorable  unless  it  assumes  an  inflammatory  or  typhoid  type.  I 
should  confidently  expect,  under  proper  treatment,  to  see  at  least 
two-thirds  of  such  patients  recover  in  six  months  or  in  less  time. 

Insanity  of  Lactation. — The  symptoms  are  of  an  asthenic  type, 
and  the  patients  are  markedly  anemic.  Full  feeding,  stimulants  and 
ferruginous  tonics  are  indicated.  Melancholia  is  the  most  frequent 
psychical  symptom.  It  is  a  disease  of  anaemia  and  exhaustion.  The 
prognosis  is  good.  The  great  majority  of  cases  became  insane  after 
the  fifth  month  of  nursing. 

Climacteric  Insanity. — At  least  6  per  cent,  of  neurotic  women  at 
this  period  of  life  become  insane.  From  44  to  48  years  of  age  is 
the  age  specially  liable  to  these  attacks.  The  cause  of  this  type  of 
insanity  is  a  pathological  condition  of  the  uterus  and  ovaries.  The 
record  of  159  cases  admitted  into  the  West  Riding  Asylum,  taken 
from  the  West  Riding  Med.  Reports,  vol.  vi.,  for  1876,  shows  that  the 
principal  psychical  symptoms  in  all  these  cases  were  delusions  of  fear 
and  persecution,  with  depression.  There  were  found  cases  of  simple 
depression  without  hallucinations  and  with  the  intellect  intact,  but  in 
some  instances  with  great  nervous  irritability  and  general  hyperaes- 
thesia. 

Another  class  of  cases  presented  depression  combined  with  affec- 
tions of  the  emotions  and  the  intellect,  hallucinations  of  sight  and 
hearing,  and  delusions  of  a  depressing  character  being  present. 

Another  class  of  cases  presented  delusions  of  fear,  suspicion  and 
persecution,  as  the  most  typical  symptoms,  with  hallucinations  of 
sight  and  hearing  and  maniacal  excitement.  A  case  now  under  our 
treatment  is  connected  with  the  cessation  of  the  catamenia.     The 


TREATMENT    OF    INSANITY.  259 

lady  is  47  years  of  age.  It  is  the  first  attack,  and  no  hereditary  his- 
tory of  insanity  can  be  discovered.  The  disease  or  mental  derange- 
ment commenced  with  simple  depression,  sluggish  bowels,  furred 
tongue,  loss  of  appetite  and  of  sleep,  and  hallucinations  of  hearing. 
She  told  me  that  she  heard  people  in  the  house  talking  about  her 
constantly,  accusing  her  of  appropriating  things  that  did  not  belong 
to  her,  etc.  She  also  imparted  to  me  very  confidentially  in  a  whis- 
per, that  there  had  been  secreted  in  a  lounge  in  the  room  she  occu- 
pied a  fuse,  which  was  connected  with  some  explosives,  and  that  the 
gentleman  who  owned  the  house  was  about  to  cause  a  great  explo- 
sion, which  would  kill  every  one  in  the  house.  She  would  walk  out, 
wring  her  hands  and  cry  bitterly,  lest  herself  and  husband  should 
become  the  victims  of  this  "  conspiracy,"  as  she  termed  it.  I  sug- 
gested the  advisability  of  a  change  of  residence,  to  which  she 
promptly  acceded,  and  the  treatment  was  commenced  by  a  mercurial 
cathartic  followed  by  salines.  Vaginal  examination  revealed  dis- 
placement of  the  uterus  with  engorgement  and  inflammation.  The 
nurse  was  directed  to  use  the  hot  vaginal  douch  of  two  gallons  daily, 
and  a  pledget  of  absorbent  cotton  steeped  in  glycerine  was  inserted 
daily  and  left  for  four  hours  in  contact  with  the  uterus.  The  dis- 
placement was  remedied,  and  the  left  ovary,  which  was  enlarged  and 
tender,  thoroughly  blistered.  Continued  warm  baths  of  a  tempera- 
ture of  100°,  with  cold  to  the  head,  were  ordered  and  continued 
daily  for  three  weeks.  A  tonic  of  iron  and  quinine  was  ordered  ter 
die  before  meals.  Static  electricity  was  employed,  the  patient  being 
placed  on  the  insulated  platform  and  sparks  taken  from  the  spine, 
which  was  tender  and  irritable.  This  patient  has  now  been  under 
treatment  for  six  and  a  half  weeks.  Her  delusions  and  hallucina- 
tions have  entirely  disappeared ;  she  eats  well,  sleeps  well,  with  her 
night  mixture  of  chloral  hydrate  15  grains  and  fluid  extract  hyos- 
cyamus  gtts.  x.,  and  is  cheerful  and  happy  and  constantly  busy.  I 
think  she  will  make  an  excellent  recovery,  and  if  so  will  probably 
have  no  relapse. 

Insanity  from  Abdominal  Disorders. — These  cases,  which  are  usu- 
ally referable  to  morbid  states  of  the  colon  and  liver,  are  character- 
ized by  melancholia  and  general  wretchedness.  They  are  very  apt 
to  be,  we  think,  cases  who  inherit  a  tendency  to  insanity.  This  con- 
dition is  very  well  illustrated  by  the  following  case,  about  which  we 
were  recently  consulted  :  A  gentleman  of  perhaps  60  years,  by 
occupation  a  teacher,  and  a  very  close  student,  has  been  for  years 


260  PSYCHOLOGICAL    MEDICINE. 

gradually  lapsing  into  insanity.  There  has  been  chronic  constipa- 
tion for  years,  due  probably  to  defective  action  of  the  muscular  coats 
of  the  colon,  a  condition  which  Professor  Samuel  G.  Armor,  of 
Brooklyn,  ably  explained  in  an  article  on  "  ]\Iorbid  States  of  the 
Colon,"  published  a  few  years  ago.  The  patient's  father  committed 
suicide  years  ago.  For  some  time — two  or  three  years — the  gentle- 
man referred  to  has  been  rendered  most  miserable  by  the  idea  that 
he  was  a  very  wicked  man ;  that  he  had  committed  unpardonable 
sins,  and  should  be  eternally  lost.  His  life  has  always  been  excep- 
tionally correct.  He  now  has  no  ability  to  apply  his  mind,  and  these 
self-tormenting  accusations  never  leave  him,  and  he  meditates  suicide 
to  escape  from  his  misery.  We  advised  opening  the  bowels  thor- 
oughly with  seven  grains  of  calomel,  followed  by  salines,  to  be  fol- 
lowed by  a  pill  of  aloes  2  grains  and  ox-gall  4  grains  ter  die,  until 
he  was  thoroughly  purged  and  all  excrementitious  matter  removed. 
To  act  on  the  liver,  a  course  of  dilute  nitro-muriatic  acid,  Ti^xv.  ter 
die,  to  be  given,  and  a  continued  course  of  warm  baths,  with  gradu- 
ally increasing  doses  of  opium,  commencing  with  20  minims  of 
dialyzed  opium,  which  is  of  the  same  strength  as  laudanum,  ter  die, 
and  increase  it  to  that  point  where  the  gloom  of  melancholia  should 
yield  to  cheerfulness.  He  has  started  for  the  mountains  to  pursue 
this  treatment,  and  will  doubtless  improve  very  much,  but  the  fact 
of  the  strong  direct  inheritance  makes  perfect  recovery  problem- 
atical. 

Post-Febrile  Insanity. — Bucknill  and  Tuke,  Nasse,  Sydenham,  Pinel, 
Baillarger,  Aubanel,  Thore,  Falret,  Sauret,  Griesinger,  and  Hanfield 
Jones  all  report  cases  of  this  type  of  insanity.  These  cases  are  as- 
thenic in  t}^pe,  and  require  quinine,  arsenic,  the  mineral  acids,  and 
stimulants,  with  a  generous  diet. 

Insanity  may  be  the  result  of  rheumatism  and  cardiac  disease. 
There  may  be  melancholia,  mania,  or  chorea-like  attacks.  The 
urine  may  be  loaded  with  lithates.  The  choreic  movements,  paraly- 
sis of  motor  power,  hallucination  of  the  senses,  poor  memory,  de- 
lirium, with  high  temperature,  the  symptoms  all  decreasing  as  the 
temperature  subsides,  point  to  a  poisoning  of  the  cerebral  centres 
by  a  vitiated  blood  plasma.  Specific  treatment  by  alkaline  and  sali- 
cylic acid  for  the  rheumatism,  the  carbonate  or  citrate  of  lithia  and 
the  free  use  of  Poland  water,  with  tonics,  should  give  good  results. 
The  insanity  of  cardiac  disease  is  associated  with  endocarditis  or 
pericarditis,  and  is  only  temporary  generally.     The  psychical  symp- 


TREATMENT    OF    INSANITY.  26 1 

toms  are  those  of  a  taciturn  melancholy  and  hallucination.  It  is, 
according  to  Dr.  Burman,  a  hypochondriacal  melancholia,  or  a 
monomania  of  suspicion,  and  the  patients  are  sullen,  morose,  or 
impulsive. 

Insanity  has  been  found  to  be  associated  with  gout  in  some  in- 
stances, the  prevailing  type  being  melancholia.  Dr.  Savage  and  Dr. 
Bertheir  report  cases,  the  latter  saying  that  sometimes  the  gouty 
symptoms  disappear  and  become  lost  in  the  insanity,  which  then 
passes  into  the  choreic  and  incurable  stage  of  dementia.  He  also 
says  that  it  shows  a  preference  for  the  form  of  general  mania.  Buck- 
nill  and  Tuke  say  that  cases  are  frequently  met  with  in  society  which 
are  marked  by  symptoms  of  unfounded  dread,  especially  on  awaking 
from  sleep  in  the  early  morning,  in  which  there  is  a  gouty  diathesis, 
and  suspicion  is  aroused  that  there  is  a  causal  connection  between 
the  bodily  condition  and  the  mental  anguish.  This  suspicion  is  con- 
firmed by  the  marked  success  of  treatment  founded  upon  this  sup- 
position. 

Phthisical  Insanity. — There  is  a  very  close  relation  existing  between 
phthisis  and  insanity.  So  often  have  I  seen  this  that  I  invariably  in- 
quire if  there  is  consumption  in  the  family,  and  I  think  that  in  almost 
half  my  cases  I  have  found  this  disease  tyi\st\r\g,  instead  of  a  neurosis, 
in  a  family  strongly  tainted  with  insanity.  I  have  also  known  of  a 
tendency  to  phthisis  disappearing  upon  marriage  and  the  family 
neurosis  taking  its  place  in  at  least  two  instances.  I  think  that  in- 
sanity, associated  with  phthisis,  is  most  apt  to  be  associated  with 
melancholia,  with  a  tendency  to  dementia.  At  least,  such  has  been 
my  own  experience.  Dr.  Clouston  thinks  that  the  maniacal  cases 
are  the  most  apt  to  end  in  dementia  and  the  melancholic  cases 
to  remain  stationary,  and  his  experience  doubtless  includes  many 
more  cases  than  my  own,  and  I  therefore  regard  it  as  more  valu- 
able, as  his  researches  in  this  direction  have  been  very  valuable 
to  the  profession  and  have  been  watched  by  myself  with  great 
interest.  He  speaks  of  the  acute  stage  of  mania  or  melancholia 
as  being  of  short  duration  and  succeeded  by  an  irritable,  excitable, 
sullen,  and  suspicious  state.  There  is  a  want  of  fixity,  he  says,  in 
their  mental  condition,  unaccountable  little  attacks  of  excitement, 
lasting  only  a  short  time,  unprovoked  paroxysms  of  irritability  and 
passion  in  a  subdued  form.  There  is  a  disinclination  to  enter  into 
any  kind  of  amusement  or  continuous  work,  and  if  this  is  overcome, 
there  is  no  interest  manifested  in  the  employment.     It  might  be 


262  PSYCHOLOGICAL    MEDICINE. 

called,  he  says,  a  mixture  of  subacute  mania  and  dementia.  The 
depression  is  general,  and  there  is  no  fixed  delusion.  If  there  is 
any  single  tendency  that  characterizes  these  cases,  it  is  to  be  sus- 
picions. 

From  my  own  experience,  I  think  Dr.  Clouston's  excellent  de- 
scription of  the  mental  symptoms  of  insanity  associated  with  phthisis, 
is  perfectly  diagnostic,  and  the  profession  owes  him  thanks  for  his 
laborious  researches  in  this  field.  Twenty-five  per  cent,  of  Dr.  Clous- 
ton's  cases  exhibited  a  suicidal  tendency.  The  px-ognosis  is  bad.  Cod- 
liver  oil  and  full  feeding,  with  mountain  air  or  any  climate  where  the 
patient  can  live  most  of  the  time  out  of  doors,  with  port  wine  at 
meals,  offer  the  best  chance  of  cure  in  the  early  stages,  together  with 
the  phosphates.  I  generally  use  the  liquor  acid,  phosphorici  comp., 
Dr.  William  Pepper's  formula,  and  I  give  morphia  to  those  suicidally 
inclined. 

Syphilitic  Insanity. — This  comparatively  rare  form  of  mental  dis- 
ease presents  itself,  according  to  Drs.  Bucknill  and  Tuke,  under  two 
forms :  congenital  weakness  of  mind  and  acquired  insanity.  The 
most  frequent  symptoms  are  those  of  progressive  dementia,  with 
considerable  loss  of  memory,  but  without  expansive  ideas,  preceded 
by  a  period  of  hypochondriacal  melancholy.  During  the  early 
form  of  it  we  may  meet  with  all  the  known  forms  of  mental  disease, 
but  rarely  acute  mania.  In  addition  to  the  pains  in  the  head,  there 
may  be  affection  of  the  motor  or  sensory  centres,  the  former  present- 
ing many  symptoms  in  common  with  general  paralysis.  This  in- 
sanity may  come  on  immediately  after  infection,  according  to  the 
same  authority,  or  be  preceded  by  cerebral  attacks,  either  of  an  epi- 
leptic or  apoplectic  nature,  dementia  gradually  and  insidiously  super- 
vening. Wille  gives  three  forms:  ist.  The  irritative  simple  form, 
generally  due  to  an  anaemic  state.  2d.  A  state  marked  by  general 
mental  disorder,  due  to  meningitis  and  softening;  and  3d.  A  state 
characterized  by  psychical  disturbance,  due  to  circumscribed  inflam- 
matory softening,  atheroma  of  the  vessels,  and  gummous  neoplasm 
of  the  brain  and  membranes. 

Dr.  Mickle  gives  the  following  symptoms  as  occurring  in  his  cases : 
Convulsive  symptoms  of  various  kinds,  dementia  and  hemiplegia, 
apoplectic  symptoms  or  coma,  drowsiness,  somnolence,  especially  in 
the  latter  periods,  with  a  great  variety  of  mental  symptoms  occurring 
during  the  earlier  periods.  Headache,  aphasia,  difficult  articulation, 
and  paralysis  of  cranial  nerves  are  often  found,  and  vomiting,  blind- 


TREATMENT   OF   INSANITY.  263 

ness  and  optic  neuritis  are  not  infrequent.  The  principal  features 
are:  ist.  A  marked  tendency  toward  mental  deterioration,  the  pre- 
dominance of  negative  intellectual  symptoms,  associated  with  weak- 
ness or  loss  of  the  moral  sense  and  a  general  inclination  to  a  degraded 
state  of  feeling.  In  some  cases  early  ok  intercurrent  outbreaks  of 
maniacal  symptoms  appear;  in  a  few  cases  there  is  causeless  depres- 
sion, fear,  or  emotional  weakness,  2d.  Motor  symptoms,  of  the  para- 
lytic or  convulsive  type.  3d.  Sensory  symptoms ;.  great  nocturnal 
pain,  especially  in  the  head ;  a-naesthesia  occurs  rarely,  and  sometimes 
impairment  of  sight,  blindness,  or  unilateral  deafness  at  times,  and 
very  seldom  hallucinations.  If,  after  death,  no  intracranial  syphil- 
itic lesions  are  found,  we  cannot  with  accuracy  attribute  the  origin 
of  the  insanity  to  syphilis,  even  though  the  patient  may  have  con- 
tracted the  disease  and  his  insanity  has  occurred  weeks  or  months 
subsequent  to  such  infection. 

The  differential  diagnosis  between  syphilitic  insanity  and  paralytic 
dementia  is,  that  in  the  former,  hypochondriacal  feelings  and  ideas  are 
more  often  noticed  at  the  very  first,  yielding  gradually  to  dementia. 
In  the  former,  prior  to  severe  apoplectiform  and  other  attacks,  the 
loss  of  memory,  confusion  of  thought,  and  tendency  to  fatuity  are 
less  marked,  advanced,  and  fixed  than  in  paralytic  dementia,  there  is 
more  an  obscuration  than  a  destruction  of  mind.  Paroxysmal  outbreaks 
of  excitement  are  rather  more  frequent  in  the  syphilitic  cases,  and 
also  such  symptoms  as  convulsions,  spasms,  paralyses,  and  sensorial 
disorders.  Insomnia  and  mental  irritability  are  more  marked  in  the 
syphilitic  patient,  but  to  this  there  are  exceptions  on  both  sides. 
When  delusions  of  grandeur  are  present,  cases  of  syphilitic  insanity 
are  to  be  diagnosed  from  general  paralysis  from  the  history  and 
symptoms  of  syphilis  ;  the  preceding  cranial  pains,  nocturnal  and  in- 
tense ;  the  exaltation  is  less  marked ;  paralysis  of  one  or  several 
cranial  nerves,  or  hemiplegia,  paraplegia,  etc.,  having  the  character 
of  syphilitic  paralysis ;  the  greater  frequency  of  optic  neuritis,  early 
amaurosis,  deafness,  local  anaesthesia,,  vertigo  or  local  rigid  contrac- 
tion ;  speech  not  accompanied  by  marked  facial  or  labial  tremors  > 
by  cerebral  or  spinal  meningitis ;,  the  variety  of  the  motor  and  sensory 
symptoms  ;  and  finally,  by  the  effect  of  antisyphilitic  treatment. 

Dr.  Clifford  Allbutt,  Dr.  Erlenmeyer,  Dr.  Hughlings  Jackson,  Dr. 
Wilks,  Dr.  Batty  Tuke,  Dr,  Buzzard,  Dr.  Clouston,  and  Dr.  Dowse 
have  all  written  ably  on  this  form  of  insanity.  Drs.  Bucknill  and 
Tuke  say  that  the  first  point  in  treatment  is  to  determine  whether 


264  PSYCHOLOGICAL    MEDICINE. 

the  syphilitic  condition  present  is  secondary  or  tertiary.  If  second- 
ary, as  indicated  by  the  presence  of  affections  of  the  skin  and  the 
mucous  membranes,  or  by  iritis,  or  pains  in  the  muscles,  joints,  and 
bones  ;  by  periostitis  and  nodes, — a  condition  in  which  the  venereal 
poison  still  exists  and  may  be  transmitted, — then  mercury  is  bene- 
ficial, and  iodine  is  of  little  or  no  service.  If  the  pathological  con- 
ditions present  are  those  which  indicate  tertiary  syphilis,  in  which 
the  venereal  poison  no  longer  exists  in  a  form  which  can  be  trans- 
mitted to  others  ;  a  state  of  cachexia,  which  is  indicated  by  inflam- 
mations of  the  fibrous  membranes ;  by  caries  and  necrosis  of  bone  ; 
by  rupia  and  sloughing  ulcers  of  the  skin  and  other  soft  parts ;  by 
deposits  of  imperfectly-organized  fibro-plastic  lymph  in  the  areolar 
tissue  of  various  parts  and  organs ;  in  such  cases  the  remedies  re- 
quired are  iodine  and  sarsaparilla,  and  mercury  is  dangerous.  Mr. 
Lane  says,  respecting  treatment,  that  the  iodide  of  potassium  should 
be  given  in  from  three-  to  ten-grain  doses  in  a  third  of  a  pint  of  the 
simple  or  compound  decoction  of  sarsaparilla  as  a  vehicle,  alternat- 
ing with  a  pill  of  two  grains  of  quinine  and  three  grains  of  confec- 
tion of  opium,  also  taken  thrice  daily.  Exceptional  cases  may  re- 
quire the  iodide  to  be  increased  to  fifteen  or  twenty  grains,  and  an 
additional  dose  of  opium  at  night  will  often  be  found  necessary. 
Opium  allays  pain  and  irritability,  and  moderates  all  excessive  secre- 
tion, preventing  unnecessary  waste. 

Alcoholic  Insanity. — This  insanity  is  very  different  from  dipso- 
mania, which  is  characterized  by  the  irresistible  craving  for  and  peri- 
odical indulgence  in  drink  to  the  point  of  complete  intoxication. 
Alcoholic  insanity  may  be  characterized  by  mania,  melancholia,  or 
chronic  mania  lapsing  into  dementia.  Hallucination  of  sight  and 
hearing,  taste  and  smell  may  all  be  present.  The  patient  may  have 
no  memory,  no  appreciation  of  his  condition  or  surroundings,  and 
his  speech  and  gait  may  be  strongly  suggestive  of  a  general  para- 
lytic. He  may  have  delusions  as  to  place,  and  insist  he  is  at  some 
quite  different  locality  from  the  one  he  occupies.  He  may  pass  his 
time  in  a  stupid  delirium  or  he  may  be  quite  furiously  maniacal. 
There  may  be  fatty  degeneration  and  atheroma  in  the  nerve-centres, 
or  there  may  be  diffuse  interstitial  sclerosis.  The  treatment  should 
consist  of  broths,  easily  digested  food,  with  quinine  and  strychnia 
for  nerve  tonics.  These  two  remedies  in  combination  have  seemed 
to  me  in  connection  with  the  liquor  acidi  phosphoric,  comp.  and  the 
oxide  of  zinc,  in  2-graiii  doses,  to  be  better  adapted  to  antagonize 


TREATMENT   OF    INSANITY.  265 

the  morbid  condition  present  and  to  lead  to  a  recovery  than  any- 
other  plan  of  treatment. 

Kleptomania  and  Pyromania  have  been  recognized  by  Mare,  Crich- 
ton  Browne,  Dr.  Savage,  Dr.  Steinau,  Tilt,  Dr.  Burman,  Jessen  and 
Ray  as  states  of  undoubted  insanity.     Bucknill  and  Tuke  would 
prefer  to  include  pyromania  under  the  head  of  destructive  insanity. 
That  these  acts  may  arise  out  of  a  purely  diseased  mental  condition  ■ 
there  is  abundant  proof  in  the  writings  of  the  authors  referred  to. 
We  should  look  in  these  cases,  say  Drs.   Bucknill  and  Tuke,  for 
hereditary  predisposition  to  insanity ;  evidence  of  mental  derange- 
ment prior  to  the  development  of  the  propensity ;  the  earliest  symp- 
toms of  general  paralysis ;  the  occurrence  of  any  physical  disorder, 
as  brain  fever;  the  suppression  of  any  discharge,  or  an  injury  to  the 
head,  puberty,  pregnancy,  the  absence  (in  most  cases)  of  any  induce- 
ment to  steal ;  the  general  conduct  of  the  individual  during  and 
after  the  act,  and  especially  (although  cunning  and  concealment  are 
consistent  with  this  form  of  mental  disorder)  voluntary  restitution  of 
stolen   goods.     Mare  says,  respecting  pyromania,  that  incendiary 
acts  are  chiefly  manifested  in  young  persons,  in  consequence  of  the 
abnormal  development  of  the  sexual  functions,  corresponding  with 
the  period  of  life  between  twelve  and  twenty.     We  should,  there- 
fore, in  these  cases  inquire  as  to  whether  there  exist  any  general 
symptoms  indicative  of  irregular  development,  or  of  critical  changes 
in  the  evolution  of  the  reproductive  system,  whether  signs  were 
present  before  the  incendiary  act  of  approaching  menstruation,  its 
derangement  or  suppression,  whether  in  epilepsy  or  catalepsy  or  an 
irregular  pulse,  vertigo,  headache,  etc.     Very  often  there  is  a  change 
in  the  character,  such  as  a  tendency  to  sadness,  insensibility,  and 
other  symptoms  of  disordered  cerebral  functions.     Mare  relates  the 
case  of  a  boy  who  struggled  for  a  year  against  such  an  impulse, 
finally  setting  fire  to  his  father's  house.     Ray  writes  of  a  girl  who 
heard  voices  commanding  her  to  burn  ;  also  of  another  girl  who  had 
an  apparition  constantly  before  her  impelling  her  to  pyromania. 


266  PSYCHOLOGICAL   MEDICINE. 


CHAPTER  XIII. 

INSANITY    IN    THE    MIDDLE   STATES. 

Insanity  is  in  the  Middle  States,  as  in  the  other  States,  increasing 
disproportionately  to  the  increase  of  population,  and  it  also  seems 
to  be  appearing  at  an  earlier  age  than  formerly,  which  latter  fact  is 
probably  due  to  hereditary  influences  which  have  gradually  become 
intensified  by  violation  of  physical  laws  in  early  life,  want  of  proper 
training,  and  too  high  pressure  in  education.  This  feverish  haste 
and  unrest  which  characterize  us  as  a  people,  the  undue  predominance 
of  the  nervous  temperament,  and  the  want  of  proper  recreation  and 
sleep,  tend  to  a  rapid  decay  of  the  nervous  system  and  to  insanity  as 
a  necessary  sequence.  It  is  much  to  be  deplored  that  intemperance 
is  operating  more  and  more  each  succeeding  year  as  a  formidable 
cause  in  the  production  of  insanity.  At  least  twenty-five  per  cent, 
of  all  cases  of  insanity  admitted  into  the  asylums  of  our  Middle 
States  is  due  either  proximately  or  remotely  to  intemperance,  which 
has  produced  a  permanently  diseased  state  of  the  brain,  due  to  the 
interference  in  the  nutrition,  growth  and  renovation  of  the  brain- 
tissue.  The  evil  does  not  stop  here  ;  for  the  offspring  of  intemperate 
parents  are  grooving  up  in  our  midst  with  weakened  if  not  actually 
diseased  nervous  systems,  and  will  inevitably  in  time  become  insane, 
diseased  or  idiots. 

The  census  returns  for  1870  of  the  United  States  showed  an  in- 
crease of  insanity  of  55  per  cent.,  while  the  increase  of  the  general 
population  had  been  22  per  cent.  The  proportion  of  insane  to  sane 
population  has  increased  from  i860,  when  it  was  shown  that  the 
entire  population  of  the  United  States  was  31,443,231,  with  an  in- 
sane population  of  23,999,  ^r  one  insane  person  in  every  13 10  of  the 
whole  population;  up  to  1875  inclusive,  when,  by  bringing  up  the 
calculation  at  the  same  rate  of  increase  for  both  sane  and  insane 
population  as  obtained  between  i860  and  1870,  we  find  the  former 
to  be  42,115,896,  and  the  latter  or  insane  population  44,148,  or  one 
insane  person  to  every  953  of  the  whole  population  of  the  United 
States. 

It  may  not  be  uninteresting  to  glance  for  a  moment  at  the  propor- 
tion of  insane  to  sane  population  in  other  countries  as  compared  with 
our  own.     In  England  there  is  one  insane  person  to  every  403  of  the 


INSANITY    IN    THE    MIDDLE   STATES,  26/ 

whole  population,  or  more  than  double  the  proportionate  number  of 
the  United  States.  In  France  there  is  an  average  of  about  one  in- 
sane person  to  every  600  of  the  whole  population.  In  Scotland 
there  is  one  insane  person  to  every  336  of  the  sane  population,  while 
in  Ireland  there  is  one  insane  person  in  every  302  of  the  population. 

In  the  United  States,  California  has  heretofore  exhibited  the  great- 
est proportion  of  insane  to  sane  population,  there  being  one  in  every 
484.  This  is  due  to  local  causes.  Massachusetts  has  shewed  the 
next  greatest  proportionate  number  of  insane,  while  the  New  Eng- 
land States,  as  a  whole,  have  a  greater  relative  increase  in  the  pro- 
portion of  the  insane  to  the  sane  population  than  has  been  observa- 
able  in  either  the  Middle,  Southern,  or  Western  States.  In  the  care 
in  the  treatment,  in  finely  appointed  institutions,  and  in  scientific  in- 
vestigations into  the  causes  of  insanity,  the  Middle  States  hold  a 
place  of  which  they  may  be  very  justly  proud. 

The  forthcoming  national  census  is  about  to  reveal  that  the  pres- 
ent number  of  the  insane,  within  the  United  States,  is  nearly  twice 
as  large  as  has  generally  been  supposed.  In  the  State  of  Massachu- 
setts, for  example,  where  thirty  years  ago  there  was  one  insane  in 
every  thousand,  there  are  now  nearly  three  to  every  thousand,  and 
other  States  show  the  same  proportion. 

Nezv  Yo7'k. — The  New  York  State  asylums  or  hospitals  for  the 
acute  insane,  in  the  order  of  their  organization,  are:  The  State  Lu- 
natic Asylum  at  Utica ;  the  Hudson  River  State  Hospital  for  the 
Insane  at  Poughkeepsie ;  the  State  Homoeopathic  Asylum  for  the 
Insane  at  Middletown ;  and  the  Buffalo  State  Asylum  for  the  Insane 
at  Buffalo. 

The  Utica  Asylum  had  626  patients  in  its  care  October  ist,  1881, 
and  it  received  412  during  the  year  ending  September  30th,  1882. 
This  gave  a  total  of  1038  patients  under  treatment  during  the  year, 
the  daily  average  being  621.  There  were  discharged,  recovered,  109; 
improved,  46;  unimproved,  235.;  as  not  insane,  13;  died,  57.  Re- 
maining September  30th,  1882,  men,  291 ;  women,  287;  total,  578. 

The  Hudson  River  State  Hospital  at  Poughkeepsie  is  only  partially 
completed,  and  has  accommodations  for  300  patients.  The  whole 
number  under  treatment  during  the  year  ending  September  30th, 
1 88 1,  was  men,  220;  women,  210;  total,  430.  The  highest  number 
in  the  asylum  at  any  one  time  was  280,  and  the  average  was  256. 
Of  those  under  treatment  during  the  year  22  recovered,  28  were 


268  PSYCHOLOGICAL   MEDICINE. 

discharged  improved,  and  80  unimproved,  i  as  not  insane,  and  26 
died.     Average  weekly  cost  of  support,  ^5.87  per  patient. 

The  State  Honiceopathic  Asylnvi  for  the  hisane  at  Middletown. — This 
institution  is  now  practically  completed,  and  it  receives  the  acute  in- 
sane whose  friends  desire  their  treatment  in  accordance  with  homoe- 
opathic principles,  from  all  parts  of  the  State.  It  has  accommoda- 
tions for  400  patients.  340  patients  were  treated  here  during  the 
year  ending  September  30th,  1881,  the  average  number  under  care 
being  213.  There  were  discharged,  recovered,  61  ;  improved,  18; 
unimproved,  30;  died,  15.  The  average  weekly  cost  the  past  year 
was  $^.tj. 

The  Buffalo  State  Asylum  for  the  Insane  is  only  partly  completed, 
the  centre  and  one  wing  being  as  yet  erected.  It  was  opened  in 
January,  1881,  and  the  number  of  patients  admitted  from  that  date 
to  September  30th  was  men,  122;  women,  97;  total,  219.  There 
were  discharged,  recovered,  19;  improved,  11  ;  unimproved,  10;  as 
not  insane,  i;  died,  22;  leaving  156  under  treatment  September 
30th,  1 88 1. 

The  total  capacity'  at  present  of  the  several  New  York  State  hos- 
pitals for  the  acute  insane  is  for  1600  patients.  When,  according  to 
the  plans  adopted,  the  Hudson  River  State  Hospital  and  Buffalo 
State  Asylum  are  completed,  2200  acute  insane  can  be  cared  for. 
The  counties  of  New  York,  Kings  and  Monroe,  embracing  a  popu- 
lation of  1,951,028,  provide  for  their  acute  as  well  as  their  chronic 
insane  in  local  institutions,  presently  to  be  described,  under  special 
statutes.  This  leaves  the  State  to  provide  only  for  the  acute  insane 
arising  in  the  other  counties,  having  a  population  of  3,133,954. 

The  New  York  State  Asyhinis  for  the  Chronic  Insane  are,  the  Wil- 
lard  Asylum  for  the  insane  at  Ovid,  and  the  Binghamton  State  Asy- 
lum for  the  chronic  insane  at  Binghamton.  These  institutions  are 
designed  for  the  chronic  pauper  insane,  transferred  from  the  county 
poor-houses  or  the  various  State  hospitals  for  the  acute  insane  as  not 
cured.  The  State  is  districted  between  the  two  institutions.  The 
charge  to  the  counties  for  maintenance  and  care  is  restricted  to  the 
actual  expense. 

The  Willard  Asylum  has  accommodations  for  1800  patients. 
There  were  1735  patients  here  September  30th,  1881,  of  whom  814 
were  men  and  921  women.  Average  number  under  care  1695,  and 
average  weekly  cost  $2.6y. 

The  Binghamton  Asylum  for  the  chronic  insane  was  formerly 


INSANITY    IN    THE    MIDDLE    STATES.  269 

the  State  Inebriate  Asylum,  converted  to  the  care  of  the  chronic  in- 
sane in  1880.  It  was  opened  for  patients  October  20th,  1881.  There 
were  66  patients  here  December  31st,  1881.  This  institution  can 
accommodate  325  patients. 

The  New  York  State  asylums  for  the  chronic  insane  can,  there- 
fore, accommodate  2100  patients. 

Respecting  the  care  of  idiots,  there  are  the  New  York  Asylum  for 
Idiots  at  Syracuse,  and  the  custodial  branch  at  Newark.  The  Syra- 
cuse institution  had  292  inmates  October  ist,  1880,  while  at  Newark, 
Wayne  County,  there  were  98  inmates  October  ist,  1880. 

The  number  of  the  insane  in  the  various  State  institutions  October 
1st,  1881,  was  10,057,  ^s  against  9537  October  ist,  1880,  and  9015 
October  ist,  1879;  of  these  4458  were  males  and  5599  females. 
With  a  population  according  to  the  last  Federal  census  of  5,082,982, 
the  proportion  of  insane  of  this  State  October  ist,  1881,  was  i  to 
every  505  inhabitants. 

Kings  County  provides  for  her  insane  in  the  Kings  County  Lunatic 
Asylum  at  Flatbush,  and  has  about  looo  or  1300  patients.  The  total 
annual  cost  is  about  ^92,400.  The  New  York  County  asylums  are 
the  New  York  City  Asylum  for  the  insane,  and  the  New  York  Lu- 
natic Asylum  on  Blackwell's  Island,  The  total  annual  cost  for  the 
New  York  City  Asylum  for  the  insane  on  Ward's  Island  is  ;^5  3,504, 
and  on  Blackwell's  Island  ^89,420. 

The  State  Asylum  for  insane  criminals  at  Auburn,  New  York,  was 
erected  in  1859,  ^^  a  cost  of  ^125,000,  and  has  842  acres  of  land  at- 
tached to  it.  The  cost  of  subsequent  additions  has  been  ;^5 2,000, 
making  the  total  cost  of  the  present  building  ^177,000.  The  annual 
expense  per  patient  is  ;^208.  The  State  appropriates  ;^  16,000  annu- 
ally for  this  institution.  The  total  annual  cost  is  ^24,544.  On 
Ward's  Island  is  also  situated  the  State  Emigrant  Insane  Asylum, 
which  provides  for  the  insane  emigrants  for  the  term  of  five  years 
from  the  time  of  their  landing  in  this  country.  This  asylum  fur- 
nishes accommodations  for  200  patients.  The  annual  expense  per 
patient  is  ;^I50,  and  the  total  annual  cost  ^22,500. 

Nezv  Jersey. — The  New  Jersey  State  Lunatic  Asylum,  at  Trenton, 
New  Jersey,  was  erected  in  1848,  and  has  attached  to  it  170  acres  of 
land.  It  has  a  capacity  of  500  patients.  The  original  cost  of  the 
building  was  ^100,000,  and  the  cost  of  subsequent  additions  has  been 
^178,000,  making  a  total  cost  of  ^278,000.  The  per  capita  cost  of 
building  is  estimated  to  be  ^556.     The  State  appropriates,  annually, 


2/0  PSYCliOLOGICAL    MEDICINE. 

;$8ooo  for  the  asylum.  Five-sixths  of  the  patients  are  paupers,  at 
;^4.50  per  week,  paid  by  counties.  Among  the  patients  in  this  asy- 
lum are  included  the  convict  insane,  who  have  been  transferred  to 
the  institution  from  the  State  prison  by  virtue  of  the  twelfth  section 
of  the  Act  of  the  Government  and  Regulation  of  the  State  Prison, 
approved  March  26th,  1869. 

The  new  asylum  is  situated  at  Morristown,  New  Jersey,  and  has 
been  erected  at  a  projected  cost  of  ^2,250,000,  and  is  one  of  the  finest 
large  institutions  in  this  country,  if  not  in  the  world.  The  site  is 
admirably  selected,  and  covers  about  400  acres  of  land,  Avhich  cost 
about  ^80,000.  The  asylum  has  a  capacity  of  800  patients.  The 
per  capita  cost  of  building  is  estimated  at  I2802.  The  water-works 
cost  ^20,000,  and  the  water  supply  is  said  to  be  four  times  enough 
to  meet  the  ordinary  wants  of  the  institution.  The  building  has  a 
frontage  of  1250  feet,  and  it  is  a  mile  and  a  quarter  around  it,  outside 
of  the  foundation  line.  It  is  a  four-story,  semi- Gothic  structure,  built 
of  syenitic  granite,  quarried  on  the  grounds.  All  the  main"  materials 
for  the  building  were  also  obtained  on  the  grounds — the  stone,  the 
clay  for  brick,  etc.  Brick  was  made  at  the  rate  of  80,000  per  day, 
about  15,000,000  having  been  used  in  the  construction. 

Pennsylvania. — Pennsylvania  has  five  State  hospitals, — Dixmont, 
Norristown,  Harrisburg,  Warren,  Danville — for  the  insane,  each  of 
which  provides  accommodations  for  500  patients,  and  another  is  to 
be  erected  in  Philadelphia.  There  is  also  a  Friends'  hospital,  at 
Frankford,  Pennsylvania.  The  city  of  Philadelphia  is  entitled  to  the 
credit  of  making  the  first  regular  provision  for  the  insane  ever  made 
in  America.  In  175 1  the  Pennsylvania  Hospital,  at  Philadelphia, 
was  incorporated  by  the  Provincial  Assembly,  for  the  purpose  of 
providing  for  the  indigent  sick  and  for  the  care  and  cure  of  the  insane. 
The  first  patient  placed  for  treatment  of  insanity  was  admitted  to  that 
hospital  February  nth,  1752. 

The  second  institution  was  the  asylum  at  Williamsburg,  Virginia, 
opened  1773.  At  the  present  day  we  have  in  operation  in  the 
United  States,  I  think,  seventy-six  hospitals  for  the  insane,  which 
will  accommodate  29,000  patients.  Since  the  establishment,  in  175 1, 
of  the  Pennsylvania  hospital,  with  its  sound  declaration  of  principles, 
which,  even  at  that  time,  recognized  insanity  as  a  physical  disease 
capable  of  cure,  up  to  1805,  when  Dr.  Benjamin  Rush  delivered  lec- 
tures on  insanity,  with  clinical  instruction  in  his  wards,  and  down  to 
the  present  time,  when  the  hospital  is  presided  over  by  the  able 


PROVISION    FOR   THE    CHRONIC    INSANE.  2/1 

specialist  in  mental  disorders,  Dr.  Thomas  S.  Kirkbride,  and  when 
the  State  laments  the  loss  of  the  late  eminent  alienist,  Dr.  Ray,  Penn- 
sylvania has  maintained  a  position  in  the  application  of  State  medi- 
cine to  the  treatment  of  insanity  of  which  she  may  be  justly  proud. 
A  separate  institution  is  much  needed  in  this  State,  for  the  criminal 
insane.  It  is  estimated  that  in  June,  1883,  there  will  be  6093  insane 
persons  living  under  the  present  system  of  treatment. 

The  insane  in  Delaivare  are  scattered  all  over  the  State  in  alms- 
houses, jails,  etc.,  and  many  of  them  are  provided  for  in  the  Penn- 
sylvania hospital. 

In  this  connection  it  is  both  appropriate  and  proper  to  say  a  word 
in  remembrance  of  the  late  Dr.  I.  Ray,  of  Philadelphia,  by  whose 
knowledge  and  experience  so  many  of  us  have  profited.  He  was 
born  at  Beverly,  Massachusetts,  January  i6th,  1807.  Graduated  at 
Harvard  Medical  School  in  1827.  In  1841  he  was  appointed  super- 
intendent of  the  Augusta,  Maine,  State  Hospital  for  the  Insane, 
remaining  there  until  1846,  when  he  assumed  charge  of  the  Butler 
Hospital,  at  Providence,  Rhode  Island,  where  he  remained  until  1867, 
when,  by  reason  of  failing  health,  he  resigned  and  moved  to  Phila- 
delphia. He  did  a  great  deal  for  the  medical  profession  by  his  able, 
scientific,  and  learned  writings,  and  was  an  expert  of  vast  knowl- 
edge and  ripe  experience  in  mental  medicine.  He  was  one  of  the 
pioneers  in  psychological  medicine  in  this  country,  and  it  is  owing 
to  him  that  much  advance  has  been  made  in  the  right  direction. 
His  works  are  written  in  beautiful  English,  and  will  take  their  place 
as  classical  treatises  on  psychological  medicine.  He  died  March 
31st,  1881. 


CHAPTER  XIV. 

PROVISION    FOR    THE    CHRONIC    INSANE. 

From  a  thorough  and  extended  examination  of  the  reports  of  our 
insane  asylums — and  these  remarks  cover  not  only  the  Middle 
States,  but  apply  equally  as  well  to  all  of  the  States — it  seems  to  be 
very  evident  that  we  are  building  large,  expensive  institutions,  fitted 
up  with  all  the  appurtenances  demanded  by  modern  science  for  the 


2/2  PSYCHOLOGICAL   MEDICINE. 

treatment  and  cure  of  insanity,  and  that,  as  soon  as  such  institutions 
are  opened  for  the  reception  of  patients,  they  become  filled  up  with  a 
class  of  cases  three-fourths  of  whom  are  chronic  and  hopelessly 
insane  patients.  It  is  no  less  evident  that  if  proper  provision  is  not 
made  for  this  class  of  the  insane  each  State  must  build,  every  few 
years,  a  very  expensive  institution,  for  which  every  city  and  town 
must  be  heavily  taxed.  What  are  we  going  to  do  to  relieve  this 
rapidly  increasing  difficulty  ?  If  this  class  of  the  chronic  insane  are 
well  taken  care  of  they  are  going  to  live  in  this  hopelessly  insane 
state — from  which,  at  the  utmost,  not  more  than  lo  per  cent,  will 
ever  recover — for  years,  costing  for  their  maintenance  not  less  than 
;^3.50  per  week.  It  is  a  fact  that  every  medical  superintendent  of  an 
institution  for  the  insane  must  have  noticed,  that  the  presence  of  this 
incurable  class  of  patients  exercises  a  very  depressing  and  unfavor- 
able effect  upon  the  minds  of  the  recent  and  acute  cases.  If  a  patient 
perceives  upon  admission  that  the  population  is  made  up  principally 
of  patients  who  have  been  inmates  for  years  and  for  whom  no  hope 
of  cure  is  entertained  by  the  medical  officers,  and  that  few  patients 
go  out  restored  to  health,  the  moral  effect  must  necessarily  be  de- 
pressing and  disastrous  upon  the  mind  of  such  a  patient  and  tend  to 
retard  his  own  recovery.  At  present  many  large,  fine  institutions, 
instead  of  being,  as  they  were  originally  intended  to  be,  hospitals 
for  the  treatment  and  aire  of  the  insane,  are  merely  asylums  and  recep- 
tacles for  the  retention  of  patients  at  an  enormous  expenditure  of 
money  for  architectural  display.  The  overcrowding  of  such  institu- 
tions by  the  retention  of  the  chronic  insane  precludes  the  possibility 
of  proper  classification  or  proper  ventilation.  By  transferring  this 
class  of  the  chronic  insane  and  leaving  the  class  of  recent  and  curable 
insane,  we  derive  many  advantages.  First  and  most  important,  the 
patients  understand  that  they  are  in  a  hospital,  that  they  come  to  be 
cured  of  a  physical  disease,  and  that,  by  submitting  to  the  treatment 
and  discipline  of  the  institution,  they  ivill  be  cured.  Secondly,  the 
superintendents  will  have  at  their  disposal  ample  room  for  proper 
classification,  good  ventilation,  amusements,  and  recreation.  The 
present  system  of  asylum  management  is  defective  and  expensive  be- 
yond the  ability  of  the  State  to  meet  the  demand,  and  tends  directly 
to  increase  the  number  of  the  chronic  insane,  as  90  per  cent,  of  the 
capacity  of  all  of  our  State  institutions  is  now  occupied  by  the  chro- 
nic insane  to  the  exclusion  of  recent  and  curable  cases.  This  class 
of  cases  often  become  chronic  and  incurable  cases  in  many  of  our 


PROVISION   FOR    THE    CHRONIC    INSANE.  2/3 

States  before  they  can  obtain  the  proper  curative  hospital  treatment, 
which,  if  applied  in  time,  would  have  resulted  in  a  speedy  cure  and 
restoration  to  their  families,  and  a  saving  of  their  productive  power 
to  the  commonwealth.  From  an  extended  examination  of  the  sta- 
tistics of  the  State  insane  asylums  in  the  United  States  in  1875,  I 
found  that  the  total  cost  of  55  of  these  institutions  was  not  far  from 
;^29,879,258.  This  made  an  average  cost  for  each  of  these  institu- 
tions of  ^543,259,  and  an  average  per  capita  cost  of  ;^I074  for  each 
of  the  asylums  in  our  country.  Now  I  maintain  that  no  State  can 
afford  to  provide  for  the  chronic  insane  at  such  a  per  capita  cost  of 
hospital  construction  when  they  can  be  provided  for  at  a  per  capita 
cost  of  construction  of  ^300  by  providing  for  them  plain,  substan- 
tial buildings.  It  would  be  very  easy  and  practicable  to  erect  such 
buildings,  accommodating  50  patients,  for  ;^i 5,000  each,  while  no 
building  accommodating  the  number  that  four  such  cottages  or  build- 
ings would  provide  for  could  be  built  for  less  than  ;^200,ooo. 

For  the  chronic  and  harmless  insane,  we  do  not  need  so  many 
attendants  or  such  costly  accommodations  as  for  acute  and  recent 
cases.  For  the  chronic  insane  we  need  plain  but  substantial  build- 
ings, which  should,  I  think,  be  located  on  a  large  farm,  so  that  the 
patients  could  be  employed  out-of-doors.  In  this  way  these  patients 
could  be  made  producers,  and  could  be  supported  at  comparatively 
little  cost  to  the  State,  and  at  the  same  time  they  would  have  the 
benefits  accruing  from  a  good,  plain,  country  style  of  living,  with 
an  abundance  of  fresh  air,  sunlight  and  regular  and  systematic  occu- 
pation. By  such  a  course  of  treatment  many  would  improve  in  gen- 
eral health,  and  some  would  probably  recover  who  would  never 
have  been  benefited  if  they  had  been  confined  in  an  asylum.  Of 
the  thousand  patients  admitted  to  the  asylum  for  the  chronic  in- 
sane at  Tewksbury,  Mass.,  during  the  eight  years  of  its  existence, 
about  one  hundred  have  recovered  or  improved  by  outdoor  work, 
and  the  experiment  is  regarded  as  a  decided  success.  The  ex- 
pense has  averaged,  I  think,  not  far  from  ^100  a  year  for  each  in- 
mate, and  it  is  stated  by  competent  authority,  that  the  patients  are 
as  well  cared  for  as  they  were  previous  to  their  admission.  The  estab- 
lishment in  1869,  of  the  Butler  Asylum  for  the  chronic  insane  in 
Rhode  Island,  was  found  to  be  a  very  successful  experiment.  It  is 
a  well-managed  institution,  and  the  trustees  say  regarding  it,  that 
"its  result  is  to  enlarge  the  capacity  of  the  hospital  for  the  treatment 
of  recent  cases  of  insanity,  and  thereby  to  increase  its  beneficial 


274  PSYCHOLOGICAL   MEDICINE. 

agency  as  a  curative  institution."  Quite  a  number  of  patients  have 
recovered  through  the  agency  of  the  outdoor  work,  and  it  is  stated 
that  the  patients  are  better  cared  for  than  before  coming  to  this  in- 
stitution. The  annual  saving  to  the  State  of  Rhode  Island  is  stated 
to  be  over  ;^  12,000,  while  the  amount  saved  annually  to  the  State  of 
Massachusetts  by  the  establishment  of  the  Tewksbury  Asylum,  is 
stated  to  be  ^25,000. 

The  Willard  Asylum  for  the  chronic  insane  at  Ovid,  New  York,  re- 
garded by  many  as  an  experiment  of  doubtful  expediency,  has  proved, 
under  the  skilful  management  of  its  able  medical  superintendent,  Dr. 
John  B.  Chapin,  to  be  a  highly  successful  measure.  The  trustees  say, 
"  The  idea  heretofore  promulgated  that  the  chronic  insane  could  not 
be  so  Avell  cared  for  in  a  separate  asylum,  and  that  it  was  better  to 
retain  them  in  a  hospital  with  recent  and  acute  cases,  has  proved  on 
trial  here  to  be  a  fallacy." 

To  deal  with  the  steadily  increasing  mass  of  lunacy  is  a  problem 
which,  as  time  goes  on,  becomes,  by  its  magnitude,  more  and  more 
difficult  of  solution.  There  can  be  no  doubt  that  the  only  way  of 
checking  the  growth  of  lunacy,  is  by  treating,  in  properly  organized 
hospitals,  the  recent  cases  as  they  occur,  and  that  cannot  be  effectively 
done  until  our  present  asylums  are  eased  of  some  of  the  dead  weight 
of  chronic  insanity  which  fills  their  wards  and  hampers  their  curative 
powers.  The  great  objection  which  has  been  urged  by  those  op- 
posed to  the  separation  of  the  recent  and  chronic  insane,  has  been  that 
the  latter,  in  institutions  designed  for  them  alone,  would  be  neglected 
and  abused,  and  they  would  not  receive  proper  medical  attention 
and  care.  The  results  thus  far  have  not  confirmed  these  fears. 
Under  all  circumstances  such  an  institution  should  be  presided  over 
by  a  medical  superintendent  of  equal  ability  and  capacity  to  those  at 
the  head  of  hospitals  for  the  recent  insane,  and  no  attempt  should  be 
made  to  put  such  patients  on  a  poor,  meagre  or  insufficient  diet,  and 
they  never  should  be  neglected  or  abused.  By  having  these  asylums 
located  on  large  farms,  we  secure  to  the  patients,  as  I  have  previously 
remarked,  occupation,  fresh  air  and  sunlight,  and  a  good  nourishing 
country  style  of  living,  and  if  there  are  any  possibilities  of  recovery 
in  any  of  the  patients,  such  a  plan  of  treatment  will  develop  them. 


LUNACY    IN    ENGLAND.  2/5 


CHAPTER  XV. 


LUNACY    IN     ENGLAND. 


In  the  year  i860  the  total  registered  number  of  the  insane  in  Eng- 
land and  Wales  was  38,058  ;  in  1870,  54,713;  and  in  1880,  71,191. 
Insanity,  however,  has  not  doubled,  but  there  has  been  an  increas- 
ing readiness  to  place  persons  as  lunatics  in  establishments.  In 
England  43  per  cent,  of  the  private  patients  are  in  private  asylums. 
There  are  sixty  county  and  borough  asylums  in  England,  containing 
40,000  beds.  The  average  cost  per  bed  has  been  not  quite  ;^20O. 
The  weekly  cost  of  each  patient  is  los.,  andthe  yearly  cost  ;!{^40. 
They  are  governed  by  a  committee  of  the  Justices  of  the  Peace, 
under  the  control  of  the  Secretary  of  State  for  the  Home  Department. 

Two  of  the  best  of  the  English  county  asylums,  are  that  for  Sussex 
at  Hayward's  Heath,  and  that  for  Surrey  at  Brookwood.  The  State 
Asylum  for  the  criminal  insane  is  located  at  Broadmoor.  The  four 
great  metropolitan  asylums,  which  hold  6600  lunatics,  are  situated  at 
Planwell,  Colony  Hatch,  Banstead  and  Wandsworth.  There  are  also  in 
England  fifteen  insane  hospitals,  including  the  idiot  asylums  at  Earls- 
wood  and  Lancaster,  where  the  insane  of  the  upper  and  middle 
classes  are  treated. 

Lunacy  in  Scotland. — In  1858' the  Commissioners  in  Lunacy  for 
Scotland  entered  upon  their  duties,  at  which  time  the  insane  regis- 
tered population  amounted  to  5823  persons.  On  January  ist,  1881, 
there  were  under  treatment  a  total  number  of  10,012  patients.  There 
have  been  several  important  improvements  introduced  in  Scotland, 
in  the  mode  of  treating  patients;  the  abolition  of  walled  airing  courts  ; 
the  disuse  of  locked  doors;  and  the  extension  of  the  practice  of  giv- 
ing liberty  on  parole. 

In  the  Fife  and  Kinross  Asylum,  containing  330  inmates,  only 
two  wards,  one  for  20  female  patients  and  one  for  30  male  patients, 
are  kept  locked. 

In  the  Barony  Asylum  at  Lenzie,  which  contains  500  patients, 
there  is  free  communication  between  all  the  wards,  as  well  as  free 
egress  from  each  of  them  to  the  general  grounds  of  the  asylum. 

The  Commissioners  of  Lunacy  are  united  in  their  commendation  of 


2/6  PSYCHOLOGICAL   MEDICINE. 

the  arrangements  existing  in  the  private  asylums  of  Scotland,  and 
in  no  single  instance  has  any  complaint  been  made,  either  against 
the  administration  or  the  building. 

The  following  are  the  revised  orders  respecting  the  case-books  in 
English  asylums  : 

"The  Commissioners  in  Lunacy,  by  virtue  of  the  power  vested  in 
them  by  the  act  of  Parliament,  passed  in  the  session  holden  in  the 
8th  and  9th  years  of  the  reign  of  her  present  ^Majesty,  entitled  'An 
Act  for  the  Regulation  of  the  Care  and  Treatment  of  Lunatics,'  do 
hereby  order  and  direct — 

"That  the  medical  '  case-book,'  by  the  said  act  directed  to  be  kept 
in  every  licensed  house  and  hospital,  shall  be  kept  in  the  form  here- 
inafter mentioned,  viz. : 

"  First.  A  statement  to  be  entered  of  the  name,  age,  sex  and  pre- 
vious occupation  of  the  patient,  and  whether  married,  single  or 
widowed. 

"  Secondly.  An  accurate  description  to  be  given  of  the  external  ap- 
pearance of  the  patient  upon  admission;  of  the  habits  of  body,  and 
temperament,  appearance  of  eyes,  expression  of  countenance,  and  any 
peculiarity  in  form  of  head,  physical  state  of  the  vascular  and  respi- 
ratory organs,  and  of  the  abdominal  viscera  and  their  respective 
functions,  state  of  pulse,  tongue,  skin,  etc.,  and  the  presence  or  ab- 
sence, on  admission,  of  bruises  or  other  injuries  to  be  noted. 

"  Thirdly.  A  description  to  be  given  of  the  phenomena  of  mental 
disorder,  the  manner  and  period  of  the  attack,  with  a  minute  account 
of  the  symptoms,  and  the  changes  produced  in  the  patient's  temper 
or  disposition ;  specifying  whether  the  malady  displays  itself  by  any, 
and  what,  illusions  or  irrational  conduct,  or  morbid  or  dangerous 
habits  or  propensities ;  whether  it  has  occasioned  any  failure  of 
memory  or  understanding,  or  is  connected  with  epilepsy,  or  ordinary 
paralysis,  or  symptoms  of  general  paralysis,  such  as  tremulous  move- 
ments of  the  tongue,  defect  of  articulation,  or  weakness,  or  unsteadi- 
ness of  the  gait. 

"  Fourthly.  Ever}'  particular  to  be  entered  which  can  be  obtained 
respecting  the  previous  history  of  the  patient ;  what  are  believed  to 
have  been  the  predisposing  and  exciting  causes  of  the  attack ;  what 
the  previous  habits,  active  or  sedentary,  temperate  or  otherwise ; 
whether  the  patient  has  experienced  any  former  attacks,  and  if  so 
at  what  periods;  whether  any  relative  has  been  subject  to  insanity' ; 
and  whether  the  present  attack  has  been  preceded  by  any  premoni- 


LUNACY    IN    ENGLAND.  2// 

tory  symptoms,  such  as  restlessness,  unusual  elevation  or  depression 
of  spirits,  or  any  remarkable  deviation  from  ordinary  habits  and  con- 
duct ;  and  whether  the  patient  has  undergone  any,  and  what  pre- 
vious treatment,  or  has  been  subject  to  personal  restraint. 

"  Fifthly.  During  the  first  month  after  admission,  entries  to  be  made 
at  least  once  in  every  week,  and  oftener  where  the  nature  of  the  case 
requires  it.  Afterwards,  in  recent  or  curable  cases,  entries  to  be 
made  at  least  once  in  every  month ;  and  in  chronic  cases,  subject  to 
little  variations,  once  in  every  three  months. 

"  In  all  cases  an  accurate  record  to  be  kept  of  the  medicines  ad- 
ministered and  other  remedies  employed,  with  the  results,  and  also 
of  all  injuries  and  accidents.  That  the  several  particulars  hereinbe- 
fore required  to  be  recorded  be  set  forth  in  a  manner  so  clear  and 
distinct  as  to  admit  of  being  easily  referred  to  and  extracted  when- 
ever the  commissioners  shall  so  require." — Office  of  Commissioners  in 
Lunacy,  19  Whitehall  Place. 

The  work  of  freeing  the  insane  from  mechanical  restraint  is  due 
primarily  to  Dr.  John  Conolly.  Dr.  Paget,  in  his  Harveian  oration, 
in  England,  in  1866,  thus  speaks  of  it:  "In  June,  1839,  Dr.  Conolly 
was  appointed  resident  physician  at  Hanwell.  In  September  he 
had  abolished  all  mechanical  restraints.  The  experiment  was  a 
trying  one,  for  this  great  asylum  contained  800  patients.  But  the 
experiment  was  successful ;  and  continued  experience  proved  incon- 
testably  that  in  a  well-ordered  asylum  even  the  strait- waistcoat 
might  be  entirely  discarded.  Dr.  Conolly  went  further  than  this. 
He  maintained  that  such  restraints  are  in  all  cases  positively  injuri- 
ous ;  that  their  use  is  utterly  inconsistent  with  a  good  system  of 
treatment ;  and  that,  on  the  contrary,  the  absence  of  all  such  re- 
straints is  naturally  and  necessarily  associated  with  treatment  such 
as  that  of  lunatics  ought  to  be, — one  which  substitutes  mental  for 
bodily  control,  and  is  governed  in  all  its  details  by  the  purpose  of 
preventing  mental  excitement,  or  of  soothing  it  before  it  bursts  out 
into  violence.  He  urged  this  with  feeling  and  persuasive  eloquence, 
and  gave  in  proof  of  it  the  results  of  his  own  experiment  at  Han- 
well, for,  from  the  time  that  all  mechanical  restraints  were  abolished, 
the  occurrence  of  frantic  behavior  among  the  lunatics  became  less  and 
less  frequent. 

"  Thus  did  the  experiments  of  Charlesworth  and  Conolly  confirm 
the  principles  of  treatment  inaugurated  by  Daquin  and  Pinel,  and 
prove  that  the  best  guide  to  the  treatment  of  lunatics  is  to  be  found 


278  PSYCHOLOGICAL    MEDICINE. 

in  the  dictates  of  an  enlightened  and  refined  benevolence.  And  so 
the  progress  of  science,  by  way  of  experiment,  has  led  men  to 
rules  of  practice  nearer  and  nearer  to  the  teachings  of  Christi- 
anity. To  my  eyes,  a  pauper  lunatic  asylum,  such  as  may  now  be 
seen  in  our  English  counties,  with  its  pleasant  grounds,  its  airy  and 
cleanly  wards,  its  many  comforts,  and  wise  and  kindly  superinten- 
dence, provided  for  those  whose  lot  it  is  to  have  the  double  burden 
of  poverty  and  mental  derangement — I  say  this  sight  is  to  me  the 
most  blessed  manifestation  of  true  civilization  that  the  world  can 
present." 

The  English  lunacy  law,  setting  aside  the  special  statutes  dating 
from  King  Edward  II.,  regulating  the  proceedings  in  chancery,  are 
the  result  of  the  legislation  of  1845,  ^^'^  consist  chiefly  of  acts 
amendmg  other  acts.  It  is  considered  in  England  that  a  bill  for  the 
general  consolidation  and  amendment  of  these  several  statutes  is  an 
urgent  necessity.  The  government  of  Lord  Beaconsfield  announced 
in  her  majesty's  speech  from  the  throne,  on  the  opening  of  Parlia- 
ment in  February,  1880,  that  such  a  measure  was  in  preparation.  It 
is  earnestly  desired  in  England  that  the  government  should  give  the 
question  of  lunacy  law  reform  their  early  and  careful  attention.  It 
has  been  suggested  by  Dr.  C.  Lockhart  Robertson,  Lord  Chancellor's 
Visitor  in  Lunacy,  that  a  royal  commission  should  be  issued  to  in- 
vestigate and  report  on  the  working,  in  detail,  of  the  lunacy  law,  and 
to  make  suggestions  for  its  consolidation  and  amendment.  What 
seems  to  be  desired  for  one  thing,  is  a  cheap  and  speedy  method  of 
placing  the  property  of  lunatics  under  the  guardianship  of  the  Lord 
Chancellor.  It  seems  to  many  in  England  desirable  that,  as  in  Scot- 
land, the  whole  lunacy  of  the  kingdom  should  be  under  the  control 
and  cognizance  of  the  lunacy  board.  Dr.  Robertson  says :  "  The 
whole  future  efficiency  of  the  English  county  asylums  depends  upon 
the  right  adjustment  of  the  relative  control  given  to  the  local  au- 
thorities through  the  new  county  boards  and  to  the  central  govern- 
ment through  the  commissioners  in  lunacy." 

There  seems  to  be  an  idea  that  the  present  lunacy  commission  of 
England  requires  both  extension  and  remodelling,  although  great 
confidence  is  expressed  in  England  in  the  ability,  industry,  and  in- 
tegrity with  which  the  existing  lunacy  law  is  administered  by  the 
commissioners.  The  English  Government  needs  to  pass  a  wide  and 
comprehensive  measure  of  lunacy  law  reform,  so  as  to  extend  to 
the  insane  of  England  the  fullest  amount  both  of  protection  and 
liberty. 


LUNACY    IN    ENGLAND. 


279 


The  Royal  Edinburgh  Asylum  at  Morningside,  is  under  the  able 
management  of  Dr.  Clouston.  This  institution  has  beds  for  two 
hundred  private  and  six  hundred  pauper  patients.  These  two 
classes  are  assigned  to  separate  buildings.  For  the  private  class 
there  are  two  or  three  cottages,  and  also  Craig  House,  which  ac- 
commodates twelve  or  fifteen  of  the  best-paying  patients.  Those 
patients  of  the  private  class  who  do  not  pay  much  more  than  the  in- 
stitution receives  for  charity  patients,  live  in  the  same  buildings 
with  the  latter  class,  but  have  a  separate  dining-room  and  a  better 
dietary  than  the  pauper  class.  The  main  building  is  in  excellent 
condition,  and  has  fine  dining-rooms,  off  from  which  run  conserva- 
tories filled  with  plants  and  flowers.  There  are  also  glass  corridors 
about  the  building  for  exercise  in  bad  weather.  There  are  open-grate 
fires  in  the  wards.  The  patients  are  employed  about  the  grounds. 
Dr.  Clouston  treats  his  excited  patients  by  keeping  them  out  all  day 
in  the  open  air,  and  gives  a  warm  bath,  followed  by  the  bromides,  at 
night.  No  mechanical  restraint  is  used.  There  are  padded  rooms 
for  violent  cases,  but  Dr.  Clouston  believes  in  full  liberty  and  little 
seclusion. 

The  three  Middlesex  asylums  are  Hanwell,  Colney  Hatch,  and 
Banstead.  Dr.  Raynor  is  the  medical 'superintendent  of  Hanwell, 
and  his  patients  are  mostly  acute  and  recent  cases.  Nearly  all  of 
his  patients  are  kept  employed  in  some  manner.  He  uses  no  me- 
chanical restraint,  but  canvas  suits  are  used  for  destructive  patients. 
In  cases  of  great  excitement,  he  employs  extra  attendants.  There 
are  padded  rooms  for  violent  cases.  Dr.  Raynor  uses  few  sedatives, 
but  keeps  his  maniacal  cases  in  open  air. 

At  Colney  Hatch,  Dr.  Marshall  has  the  superintendence  of  the 
female  department,  and  Dr.  Shephard  of  the  male  side.  No  me- 
chanical restraint  is  used,  but  they  have  strong  rooms  and  also 
padded  rooms.     Sedatives  are  seldom  used. 

Dr.  T.  Claye  Shaw  is  the  medical  superintendent  of  the  Banstead 
Asylum,  and  he  treats  his  patients  on  the  non-restraint  system.  The 
patients  are  made  to  work  whenever  possible.  They  have  mittens 
and  padded  rooms  for  bad  and  destructive  cases. 

In  Bethlehem  and  St.  Luke's  Hospitals,  the  patients  receive  few 
sedatives,  and  are  treated  on  the  non-restraint  system.  They  have 
padded  rooms  and  canvas  clothing  for  destructive  patients.  At  Beth- 
lehem there  is  one  attendant  for  every  six  patients. 

Dr.  Richard  Greene  is  the  superintendent  of  the  Northanipton 


280  PSYCHOLOGICAL   MEDICINE. 

County  Insane  Asylum  at  Berrj^wood  near  Northampton.  The 
building  accommodates  600  patients.  There  is  one  attendant  for  every 
15  patients.  Close  shutters- close  all  the  windows  in  the  single  rooms, 
and  the  other  windows  have  stops,  which  prevent  their  being  either 
raised  or  lowered  more  than  about  half  a  foot.  There  are  padded 
rooms  and  also  rooms  with  double  doors.  The  suicidal  cases  are 
placed  in  one  ward  every  night,  and  are  specially  watched.  The 
patients  occupy  single  rooms  with  doors  of  open  woodwork  to  make 
surveillance  easy.  The  patients  are  all  made  to  work,  and  all  the 
shoes  and  clothes  of  the  male  patients  are  made  in  the  shops  by 
male  patients.     Sedatives  and  the  wet  pack  are  used  as  required. 

The  Manchester  Royal  Asylum  at  Cheedle  is  run  on  the  extreme 
non-restraint  system.  There  are  no  walls  about  the  asylum  as  is 
customary  in  England.  Both  pay  patients  and  charity  patients  are 
received.  Many  patients  have  their  own  private  parlors  besides 
their  sleeping-rooms,  which  are  one  stor}^  higher  up.  In  maniacal 
cases  dark  and  padded  rooms  are  used.  Sedatives  are  used  when- 
ever needed.  Nothing  but  mittens  are  used  in  the  way  of  mechani- 
cal restraint. 

Mr.  Bailey  is  the  superintendent  of  St.  Andrew's  Hospital  at 
Northampton,  and  the  patients  come  entirely  from  the  upper  and 
middle  classes.  There  are  many  acres  of  ground,  beautifully  laid 
out  in  fine  lawns  and  gardens,  and  the  accommodations  within  are 
spacious  and  first-class  in  every  respect.  Mechanical  restraint  is  un- 
known, attendants  taking  the  place  of  restraint.  Sedatives  are  freely 
used. 

Dr.  Yellowlees  is  the  able  superintendent  of  the  Royal  Glasgow 
Asylum  at  Gartnarel.  The  pay  patients  and  charity  patients  are 
separated  in  different  buildings.  The  private  patients  take  their  meals 
in  the  corridors,  and  the  charity  patients  have  a  large  common  dining- 
room.  The  lowest  price  for  patients  is,  I  believe,  two  guineas  per 
week,  while  charity  patients  are  paid  for  by  their  parishes  at  twelve 
shillings  per  week.  The  asylum  is  run  on  the  non-restraint  system. 
Sedatives  are  freely  used  when  necessary.  Dr.  Yellowlees  secures 
the  clothing  on  destructive  patients  by  locked  buttons  and  buckles. 
There  are  many  open  fire-places. 

Dr.  C.  H.  Skae  is  the  superintendent  of  the  Ayr  District  Asylum, 
which  holds  300  patients  of  the  lower  classes. 

Dr.  Rutherford  is  the  able  superintendent  of  the  Barony  Parochial 
Asylum  at  Lenzie  near  Glasgow.     The  buildings  will  accommodate 


LUNACY    IN    ENGLAND,  28 1 

500  patients.  There  is  one  attendant  for  every  12  patients.  Open 
fire-places  are  in  use,  and  all  able-bodied  patients  work  outside.  The 
non-restraint  system  and  unlocked  doors  are  the  rule.  There  are 
workshops  for  all  the  trades.  They  have  a  farm  of  four  hundred 
acres,  and  there  are  no  fences  about  the  grounds.  Very  few  seda- 
tives are  used  here.  Maniacal  patients  are  kept  in  the  open  air; 
of  course  escapes  are  frequent.  Some  of  the  hospitals  have  sum- 
mer houses,  where  small  parties  go  out,  stay  for  two  or  three  days 
or  weeks,  and  return  again,  fresh  sets  of  patients  being  allowed  to  go 
out  in  the  same  manner.  This  is  true  of  the  Edinburgh  Asylum, 
the  Bethlehem  Hospital,  and  the  Asylum  at  Cheedle.  In  Scotland 
moleskin  garments  are  used  for  destructive  patients  who  tear  their 
clothing.  In  1881,  310  escapes  were  made  from  Scottish  asylums; 
of  these  206  were  brought  back  within  twenty- four  hours,  61  in 
less  than  a  week,  and  21  after  more  than  seven  days.  The  re- 
maining 22  did  not  return.  Accidents  during  1881  were  141;  11 
ending  fatally.* 

With  regard  to  the  increase  of  lunacy  in  Scotland  the  commis- 
sioners say :  "  The  figures  in  the  table  do  not  indicate  any  steady  or 
appreciable  increase  in  the  admission  of  private  patients  into  asylums, 
while  there  is  a  very  considerable  increase  in  the  number  of  pauper 
lunatics  registered  during  the  last  year.  This  increase  exceeds  that 
during  any  year  since  the  establishment  of  the  board,  and  amounted 
to  333,  the  number  being  337  pauper  lunatics  over  and  4  private  pa- 
tients under  the  number  for  1880.  The  distribution  also  of  pauper 
patients  in  private  dwellings  continues  to  show  considerable  increase, 
the  number  for  the  period  under  review  being  52 ;  it  should  be  re- 
membered, however,  in  this  connection,  that  in  Scotland  no  pauper 
lunatics  are  accommodated  in  private  asylums,  the  public  establish- 
ments alone  receiving  them.  The  admission  of  voluntary  patients 
in  the  year  amounted  to  38,  this  number  11  less  than  in  1880,  and 
the  same  figure  under  the  average  admission  between  1 875-79.  ^^ 
have  for  some  years  been  able  to  say  that  nothing  has  occurred  to 
indicate  any  difficulty  or  disadvantage  traceable  to  the  presence  of 

*  hisanity  in  France.. — The  four  Parisian  asylums  are  the  Bicetre,  Salpetriere,  Char- 
enton,  and  St.  Anne.  All  the  inmates  live  much  in  the  open  air.  Water,  as  a  means  of 
treatment,  is  much  used,  and  elaborate  means  for  this  are  provided.  Restraint  is  freely 
used.  Insanity  is  more  active  in  France  than  in  England  and  there  is  more  agitation. 
At  Lausanne,  in  Switzerland,  no  restraint  is  used.  Maniacal  attacks  are  milder  here 
than  in  France  and  Italy.  At  the  asylum  at  Heidelberg,  in  Germany,  leather  mittens  and 
the  wet  packare  used.to  restrain  patients.    'The  policy  of  Germany  is  that  of  non-restraint. 


282  PSYCHOLOGICAl!    MEDICINE. 

this  class  of  patients  in  asylums ;  and  we  continue  to  be  of  opinion 
that  it  is  a  useful  provision  of  the  law  which  permits  persons  who 
desire  to  place  themselves  under  care  in  an  asylum  to  do  so  in  a 
way  which  does  not  require  them  to  go  through  forms  from  which 
the}^  naturally  shrink,  and  yet  affords  sufficient  guarantee  against 
abuse.  At  the  visits  of  the  medical  commissioner  to  asylums  all 
voluntary'  inmates  are  seen,  and  they  have  then  an  opportunity  of 
making  statements  in  regard  to  their  position,  should  they  desire  to 
make  any.  Where  there  is  reason  to  suppose  that  they  in  any  way 
fail  to  understand  the  conditions  of  their  residence,  we  consider 
it  proper  to  explain  these  conditions ;  but  we  have  never  found  that 
the  nature  of  their  position  has  been  intentionally  concealed  from 
them.  Discharges  numbered  among  recovered  patients,  no  fewer 
than  1x88;  206  private  and  982  pauper.  These  figures  are  both 
higher  in  respect  to  annual  rates  and  to  averages." 

The  thirty-sixth  report  of  the  Commissioners  in  Lunacy  in  England 
yields  confirmatory  evidence  respecting  the  suspected  increase  in 
lunacy  in  that  country.  "  The  large  increase  noticed  in  the  number 
of  lunatics  last  year  is  almost  entirely  among  the  pauper  classes,  the 
private  patients  remaining  comparatively  stationary.  The  figures  for 
1 88 1  show  an  increase  of  iSoi  as  compared  with  those  relating  to 
1880;  the  average  annual  increase  of  pauper  patients  for  the  preced- 
ing years  having  been  only  1 507."  During  the  year  dealt  with  in 
this  report  17  deaths  by  suicide  occurred  in  county  and  borough 
asylums.     In  three  cases  the  patients  were  away  on  trial. 

Dr.  G.  H.  Blandford,  of  England,  in  writing  on  the  treatment  of 
insanit}'  says :  "  Our  object  should  be  to  restore  to  health  the  disor- 
dered brain,  to  cause  the  incessant  waste  to  cease,  to  promote  a  stor- 
ing and  not  an  expenditure  of  nerv^e-force.  The  brain  must  be 
nourished  by  healthy  blood.  The  quantity  of  the  latter  when  in  de- 
fect must  be  increased ;  when  its  quality  is  in  fault  it  must  be  im- 
proved ;  and  when  the  blood-flow  is  in  excess  it  must  be  checked  ; 
while  all  causes  of  disturbance  reacting  upon  the  brain  from  other 
organs  of  the  body  must  be  removed."  He  also  wisely  says  :  "  Many 
persons  at  the  very  outset  of  insanity'  may  by  removal  and  judicious 
treatment  be  cured,  if  their  friends  will  only  open  their  eyes  and 
acknowledge  the  threatening  evil,  and  not  wait,  as  they  so  often  do,  till 
compelled  by  circumstances  to  interfere,  etc.  Patients'  friends  con- 
stantly make  a  mistake ;  they  keep  the  patient  out  of  an  asylum  at 
the  time  asylum  treatment  would  cure  him,  and   send  him  there 


LUNACY    IN    ENGLAND.  283 

when  all  hope  of  cure  is  over,  and  when  as  a  chronic  lunatic  he 
would  be  just  as  well  off  out  of  one." 

"  To  procure  sleep  no  drug  in  his  experience  approaches  chloral 
in  value,  and  few  are  the  cases  where  it  is  totally  inefficacious.  He 
has  failed  to  perceive  the  pernicious  effects  attributed  to  it  by  some 
writers,  and  the  results  both  in  severe  and  slight  cases  have  been 
most  satisfactory.  In  the  melancholic  and  non-excited  cases  the 
preparations  of  opium  are  of  great  service,  alone,  or  in  combination 
with  chloral.  In  excitement,  bromide  of  potassium  is  valuable, 
alone,  or  in  combination  with  chloral,  Indian  hemp,  or  henbane. 
Calabar  bean  is  useful  in  general  paralysis.  Good  and  abundant  food 
is  an  essential  in  the  treatment  of  the  insane  ;  stimulants  are  required 
in  many  cases,  particularly  the  depressed  and  anaemic  forms,  but  in 
the  opposite,  though  often  useful,  they  in  some  cases  produce  or  in- 
crease excitement,  especially  in  the  early  stage.  With  the  food 
tonics  should  be  given,  and  those  best  suited  are,  in  the  writer's  ex- 
perience, the  mineral  rather  than  the  vegetable,  and  chief  of  all,  the 
preparations  of  iron." 

I  regard  the  following,  written  thirty  years  ago  by  the  late  emi- 
nent Dr.  Forbes  Winslow,  as  very  valuable  to  the  profession,  and 
accordingly  insert  it : 

On  the  Medical  Treatment  of  Insanity. — It  is  necessary  that  we  should,  before  being 
able  to  appreciate  the  effect  of  medical  treatment,  entertain  just  and  enlightened  views  as 
to  the  curability  of  hisanity.  I  now  speak  from  a  somewhat  enlarged  experience,  from 
much  consideration  of  the  matter,  and  I  have  no  hesitation  in  affirming  that,  if  brought 
within  the  sphere  of  medical  treatment  in  the  earlier  stages,  or  even  within  a  few  months 
of  the  attack,  insanity,  unless  the  result  of  severe  physical  injury  to  the  head,  or  con- 
nected with  a  peculiar  conformation  of  chest  and  cranium,  and  an  hereditary  diathesis, 
is  as  easily  curable  as  any  other  form  of  bodily  disease  for  the  treatment  of  which  we  apply 
the  resources  of  our  art.  It  is  a  lamentable  error  to  suppose,  and  a  dangerous,  a  false, 
and  unhappy  doctrine  to  promulgate,  that  the  disordered  affections  of  the  mind  are  not 
amenable  to  the  recognized  principles  of  medical  science.  I  again  declare  it  to  be  my 
positive  and  deliberately-formed  opinion  that  there  are  few  diseases  of  equal  magnitude 
so  susceptible  of  successful  medical  treatment  in  the  incipient  form  as  those  implicating 
the  normal  action  of  thought.  The  vast  amount  of  incurable  cases  of  insanity  which 
crowd  the  wards  of  our  national  and  private  asylums  is  pregnant  with  important  truths. 
In  the  history  of  these  unhappy  persons — these  lost  and  ruined  minds — we  read  recorded 
the  sad,  melancholy,  and  lamentable  results  of  either  a  total  neglect  of  all  efficient  cura- 
tive treatment  at  a  period  when  it  might  have  arrested  the  onward  advance  of  the  cere- 
bral mischief  and  maintained  reason  upon  her  seat ;  or  of  the  use  of  injudicious  and  unjus- 
tifiable measures  under  mistaken  notions  of  the  nature  and  pathology  of  the  disease.  In 
no  class  of  affections  is  it  so  imperatively  necessary  to  inculcate  the  importance  of  early 
and  prompt  treatment  as  in  the  disorders  of  the  brain  affecting  the  manifestations  of  the 
mind.     I  do  not  maintain  that  our  curative  agents  are  of  no  avail  when  the  disease  has 


284  PSYCHOLOGICAL   MEDICINE. 

passed  beyond  what  is  designated  the  "  curable  stage."  My  experience  irresistibly  leads 
to  the  conclusion  that  we  have  often  in  our  power  the  means  of  curing  insanity,  even 
after  it  has  been  of  some  years'  duration,  if  we  obtain  a  thorough  appreciation  of  the 
physical  and  mental  aspects  of  the  case,  and  perseveringly  and  continually  apply  reme- 
dial measures  for  its  removal ;  but  I  cannot  dwell  too  strongly  upon  the  vital  necessity 
of  the  early  and  prompt  exhibition  of  curative  means  in  the  incipient  stage  of  mental 
derangement. 

I  believe  insanitj^  (I  am  now  referring  to  persistent  insanity,  not  those  transient  and 
evanescent  forms  of  disturbed  mind  occasionally  witnessed)  to  be  the  result  of  a  specific 
morbid  action  of  the  hemispherical  ganglia,  ranging  from  irritation,  passive  and  active 
congestion,  up  to  positive  and  unmistakable  infia}7imatory  action.  This  state  of  the  brain 
may  be  confined  to  one  or  two  of  the  six  la3'ers  composing  the  hemispherical  ganglia  ; 
but  all  the  laj'ers  are  generally  more  or  less  implicated,  in  conjunction  with  the  tubular 
fibres  passing  from  the  hemispheres  through  the  vesicular  neurine.  This  specific  inflam- 
mation, from  its  incipient  to  the  more  advanced  stage,  is  often  associated  with  great  vital 
and  ner^'ous  depression.  It  is,  like  analogous  inflammation  of  other  stiuctures,  not  often 
accompanied  by  much  constitutional  or  febrile  disturbance  unless  it  loses  its  specific  fea- 
tures and  approximates  in  its  character  to  the  inflammation  of  active  cerebritis  or  menin- 
gitis. This  state  of  the  hemispherical  ganglia  is  frequently  conjoined  with  active  san- 
guineous circulation  and  congestion,  both  of  the  substance  of  the  brain  and  its  investing 
membranes.  The  morbid  cerebral  pathological  phenomena,  viz.,  the  opacity  of  the 
arachnoid,  the  thickening  of  the  dura  mater,  its  adhesions  to  the  cranium,  the  depositions 
so  often  observed  upon  the  convoluted  surface  of  the  hemispheres  and  on  the  meninges, 
the  hypertrophy,  scirrhus,  the  cancerous  affections,  the  induration,  the  depositions  of  bony 
matter  in  the  cerebral  vessels  and  on  the  dura  mater,  the  serous  fluids  in  and  the  ulcera- 
tions upon  the  surface  of  the  ventricles,  the  alterations  in  the  size,  consistence,  color,  and 
chemical  composition  of  the  vesicular  neurine  and  fibrous  portion  of  the  brain — are  all, 
in  my  opinion,  the  results,  the  sequels,  more  or  less,  of  that  specific  inflammatory  condi- 
tion of  the  hemispherical  ganglia  to  which  I  have  referred.  It  does  not  necessarily  fol- 
low that  the  fons  et  origo  mali  of  insanity  is  invariably  to  be  traced  to  the  brain.  The 
preliminary  morbid  action  and  irritation  are  often  situated  in  the  heart,  the  stomach,  the 
liver,  the  bowels,  the  lungs,  or  the  kidneys,  the  brain  being  secondarily  affected  ;  never- 
theless, in  all  cases  inducing  actual  insanity,  the  hemispherical  ganglia  are  involved  in 
the  morbid  action.  The  most  recent  pathological  doctrine  propounded  to  explain  the 
phenomena  of  insanity — I  refer  to  the  views  of  a  recent  writer — that  derangement  of 
mind  is  the  effect  of  "  loss  of  nervous  tone^''  and  that  this  loss  of  nervous  tone  is  "  caused 
by  a  premattire  a7id  abnormal  exhaustibility  of  the  vital  powers  of  the  sensorium  " — con- 
veys to  my  mind  no  clear,  definite,  or  precise  pathological  idea.  It  is  true  that  we  often 
have,  in  these  affections  of  the  brain  and  disorders  of  the  mind,  "  loss  of  nervous  tone  "  and 
"  exhaustion  of  vital  power,"  but,  to  my  conception,  these  are  but  the  effects  of  a  prior 
morbid  condition  of  the  encephalon,  the  sequelcB  of  specific  inflammation  of  the  hemispher- 
ical ganglia.  To  argue  that  insanity  is  invariably  and  exclusively  the  result  of  "loss  of 
nervous  tone,"  is  to  confound  cause  and  effect,  'ih^  post  hoc  with  the  propter  hoc ;  and 
would,  as  regards  therapeutical  measures,  act  as  an  ignis  fatuus,  alluring  us,  as  patholo- 
gists, from  the  right  and  legitimate  path.  I  feel  anxious  that  my  views  upon  this 
important  subject  should  be  clearly  enunciated  and  not  open  to  misconception.  I 
think  much  mischief  has  arisen  from  a  belief  ii  the  existence  of  active  ordinary  cere- 
bral inflammation  in  cases  of  insanity,  for  it  has  led  to  the  adoption  of  treatment 
most  destructive  to  life  and  has  seriously  interfered  with  the  permanent  restoration  of 
the    reasoning  powers.      Nevertheless,  insanity  is  occasionally  complicated  with  acute 


LUNACY    IN    ENGLAND.  285 

cerebral  symptoms  sufficient  to  justify  us  in  the  cautious  use  of  somewhat  active  meas- 
ures for  its  removal.  We  must  avoid  the  fatal  error  of  a  too  rapid  process  of  gen- 
eralization, and  be  careful  of  not  looking  to  symptoms  instead  of  to  the  disease  itself,  and 
of  permitting  ingenious  and  well-constructed  a  priori  theories  of  the  nature  of  insanity  to 
dazzle  our  imaginations  and  abstract  the  mind  from  the  steady  and  patient  investigation 
of  pathological  science  and  individual  cases  of  disease.  If  we  allow  our  judgment  to  be 
warped  by  the  inflammatory  theory  on  the  one  side  (I  am  now  speaking  of  ordinary  not 
oi  specific  inflammation),  and  conclude  that  the  excitement  of  mania  is  to  be  subdued  by 
copious  depletion  or  the  administration  of  antiphlogistic  measures ;  or  if,  on  the  other 
hand,  we  adopt  the  speculative  opinions  of  those  who  belive  that  in  every  case  of  insanity, 
irrespective  of  its  origin,  its  progress,  or  its  character,  there  exists  "  mere  loss  of  nervous 
tone  "  caused  by  "  a  premature  abnormal  e.xhaustibility  of  the  vital  powers  of  the  senso- 
rium,"  how  lamentably  shall  we  be  misled  as  to  the  real  character  of  insanity  and  in  the 
application  of  our  therapeutic  agents  !  These  circumscribed  and  partial  views  of  the 
pathology  of  insanity  often,  alas,  lead  to  serious  solecisms  in  practice.  In  90  per  cent, 
of  the  cases  of  acute  mania  there  is  found  in  the  brain  and  its  meninges  a  state  of  san- 
guineous congestion,  particularly  of  the  hemispherical  ganglia,  combined  with  alterations 
in  the  gray  nervous  matter.  In  forming  an  opinion  of  the  actual  pathological  condition  of 
the  cerebral  substance  we  should  remember  that,  particularly  in  public  asylums,  it  is  a  rare 
occurrence  for  recent  cases  to  be  admitted  ;  that  the  acute  and  subacute  active  cerebral 
conditions  have  subsided  and  the  disease  has  assumed  a  chronic  form  before  the  patient 
is  examined  and  placed  under  treatment ;  consequently  many  deductions  recorded  by 
pathologists  have  been  based  upon  the  study  of  chronic  and  not  of  acute  mania.  A  large 
percentage  of  the  cases,  before  admission  into  our  national  asylums,  have  passed  through 
the  primary  and  acute  stages,  and  have  probably  been  subjected  to  medical  treatment. 
This  fact  must  never  be  lost  sight  of  in  forming  our  opinion  not  only  of  the  nature  of  the 
disease  itself,  but  of  the  medical  treatment  necessary  for  its  cure.  In  private  practice  the 
acute  foiTns  of  insanity  are  often  met  with,  but  even  with  the  advantages  which  the  phy- 
sician can  command  of  investigating  the  earlier  stages  of  deranged  mind,  he  often  dis- 
covers that  the  mental  affection  has  been  allowed  to  exist  and  slowly  progress  for  a  con- 
siderable period,  no  treatment,  either  medical  or  moral,  having  been  adopted  for  its 
removal.  If  the  incipient  form  of  insanity,  particularly  when  it  manifests  itself  in  pleth- 
oric constitutions,  has  been  sudden  in  its  development,  is  the  result  of  physical  causes, 
and  is  connected  with  the  retrocession  of  gout,  or  is  rheumatic  in  its  character,  there  can 
be  no  doubt  the  nature  of  the  changes  induced  in  the  brain  is  more  allied  to  that  of 
inflammation  than  that  of  nervous  exhaustion.  The  attacks  from  the  slow  and  insidious 
operation  of  moral  causes  are  less  likely  to  be  accompanied  by  active  symptoms.  In 
many  instances  the  maniacal  excitement  is  asthenic  or  atonic  in  its  character,  resembling 
the  delirium  of  the  last  stages  of  typhus  fever. 

The  most  simple  classification  of  insanity — the  one  best  adapted  for  useful  and  practical 
purposes — is  its  division  into  the  acute  2lxA  chronicioxvas,;  the  insanity  ushered  in  by 
excitement  or  by  depression  into  mania  and  melancholia — amentia  and  dementia.  The 
mmute  divisions  and  subdivisions,  the  complicated  and  confused  classification  to  be  found 
in  books  may  serve  the  ostentatious  purposes  of  those  desirous  of  making  pompous  dis- 
play of  scientific  lore,  but  I  think  they  have  tended  to  bewilder  and  obscure  the  under- 
standing of  the  student  and  lead  the  man  in  search  of  practical  truth  from  the  investiga- 
tion of  the  disease  itself  to  the  mere  study  of  it^  symptoms  and  to  the  consideration  of 
unessential  points  and  shades  of  difference.  Adhering  to  this  division  of  the  subject,  each 
form  should  be  viewed  in  relation  to  its  complications  as  well  as  to  its  associated  diseases. 
Among  the  former  are  epilepsy,  suicide,  homicide,  paraplegia,  hemiplegia,  and  general 


286  psycholoctICAl  medicine. 

paralysis.     The  associated  diseases  implicate  the  lungs,  heart,  liver,  stomach,  bowels, 
kidney,  bladder,  and  skin. 

Before  speaking  of  the  preliminary  examination  of  the  patient  supposed  to  be  insane 
and  the  prognosis  in  cases  of  insanity,  I  would  premise  that  those  inexperienced  in  the 
examination  of  this  class  of  cases  would  often  arri\'e  at  false  and  inaccurate  conclusions 
if  they  were  not  cognizant  of  the  fact  that  the  insane  often  describe  sensations  which  they 
have  never  experienced,  and  call  attention  to  important  symptoms  which  have  no  exist- 
ence except  in  their  own  morbid  imaginations.  A  patient  will  tell  you  that  he  has  a 
racking  headache  or  great  pain  and  tenderness  in  the  epigastric  region,  both  symptoms 
being  the  fanciful  creations  of  his  diseased  mind.  This  is  particularly  the  case  in  the 
hysterical  forms  of  insanity,  in  which  there  always  exists  a  disposition  to  pervert  the  truth 
and  exaggerate  the  symptoms.  Again,  serious  bodily  disease  may  be  present,  the  patient 
not  being  sufficiently  conscious  to  comprehend  the  nature  of  the  questions  asked  or  able 
to  give  intelligible  replies  to  the  anxious  interrogatories  of  the  physician.  Insanity  often 
masks — effectually  obscures — other  organic  affections,  tha  greater  malady  overpowering 
the  lesser  disease.  When  Lear,  Kent,  and  the  Fool  are  standing  alone  upon  the  wild 
heath,  exposed  to  the  merciless  pelting  of  the  tempest,  Ke7it  feelingly  implores  the  king 
to  seek  shelter  from  the  "  t}"ranny  of  the  open  night"  in  an  adjoining  ho^•el ;  it  is  then 
that  Lear  gives  expression  to  the  psychological  truth  just  referred  to  : 

"  Thou  think'st  'tis  much  that  this  contentious  storm 
Invades  us  to  tlie  skin;  so  'tis  to  thee; 
But  where  the  greater  malady  is  fixed. 
The  lesser  is  scarce  felt ; 

The  tempest  in  }?iy  mind 

Doth  from  my  senses  take  all  feeling  else 
Save  what  beats  there" 

Disease  of  the  brain  may  destroy  all  apparent  consciousness  of  pain  and  keep  in  abey- 
ance the  outward  and  appreciable  manifestations  of  other  important  indications  of  organic 
mischief.  Extensive  disease  of  the  stomach,  lungs,  kidneys,  bowels,  uterus,  and  heart 
have  been  known  to  have  progressed  to  a  fearful  extent  without  any  obvious  recognizable 
indication  of  the  existence  of  such  affections.  Insanity  appears  occasionally  to  modify 
the  physiognomy  and  symptomatology  of  ordinary  diseases  and  to  give  them  peculiar  and 
specific  characteristic  features. 

Again,  it  is  necessary  for  the  physician  to  watch  the  operation  of  medicine  in  mask- 
ing important  diseases.  The  different  forms  of  narcotics,  if  given  in  heroic  doses,  often 
mislead  us  in  our  estimate  of  the  nature  of  bodily  diseases  not  directly  connected  with 
the  mental  affection.  The  most  essential  preliminarj'  matters  of  inquiry  have  relation 
to  the  age,  temperament,  previous  occupation  and  condition  in  life  of  the  patient.  It 
will  be  necessary  to  ascertain  the  character  and  duration  of  the  attack;  to  ascertain 
whether  it  has  resulted  from  moral  or  physical  causes ;  if  of  sudden,  insidious,  or  of 
slow  growth;  whether  it  has  an  hereditarj'  origin,  or  is  the  effect  of  a  mental  shock, 
or  of  mechanical  injur)-;  whether  it  is  the  first  attack,  and,  if  not,  in  what  features  it 
differs  from  pre^^ous  paroxysms.  It  will  also  be  our  duty  to  inquire  whether  it  is  com- 
plicated with  epilepsy,  paraplegia,  or  hemiplegia,  suicidal  or  homicidal  impulses.  If  any 
prior  treatment  has  been  adopted  we  must  ascertain  its  nature ;  whether  the  patient  has 
suffered  from  gout,  heait  disease,  rheumatism,  cutaneous  affection,  or  syphilis.  It  is  im- 
portant, in  cases  of  females,  to  obtain  accurate  information  in  relation  to  the  condition  of 
the  uterine  functions  and  to  ascertain  the  state  of  the  moral  affections.  We  should  also 
inquire  whether  the  patient  has  been  suspected  of  habits  of  self-abuse.     Ha\'ing  obtained 


LUNACY    IN    ENGLAND.  28/ 

accurate  information  upon  these  essential  points,  our  own  personal  observation  will  aid 
us  in  ascertaining  the  character  of  the  mental  disturbance  ;  the  configuration  of  the  head, 
chest,  and  abdomen ;  the  gait  of  the  patient,  the  degree  of  sensibility  and  volitional  power 
manifested ;  the  state  of  the  retina,  the  pulse,  the  urine,  and  temperature  of  the  scalp  and 
body  generally ;  the  condition  of  the  skin  and  chylopoietic  viscera ;  the  action  of  the 
heart,  lungs,  and  nature  of  any  existing  disease  of  the  uterus.  If  a  patient  complains  of 
any  local  mischief,  however  imaginary  it  may  appear  to  be  at  the  time,  it  is  essentially 
necessary  that  we  should  clearly  satisfy  our  minds  upon  the  point  before  dismissing  it  as 
not  entitled  to  serious  investigation.  A  patient  once  bitterly  complained  of  retention  of 
urine;  upon  examination,  the  bladder  was  found  to  be  distended  and  the  man  had  passed 
no  urine  for  twenty-four  hours.  I  was  about  to  enter  a  catheter,  when  the  patient  burst 
into  a  fit  of  laughter  and  immediately  emptied  his  bladder.  Esquirol  relates  the  case  of 
a  merchant  who,  whilst  suffering  from  melancholia,  declared  that  some  foreign  body  was 
sticking  in  his  throat.  No  notice  was  taken  of  this  supposed  fanciful  idea.  The  patient 
died,  and  an  ulcer  was  discovered  at  the  upper  third  of  the  oesophagus.  A  patient  com- 
plained of  devils  being  in  his  stomach  and  bbwels,  and  declared  that  they  were  acted 
upon  by  electric,  magnetic  agencies.  After  death  he  was  found  to  have  scirrhus  of  the 
stomach  and  chronic  inflammation  of  the  bowels.  A  patient  refused  to  eat ;  he  said  he 
could  not  swallow  his  food  without  great  pain.  As  he  had  exhibited  other  symp- 
toms of  a  disposition  to  suicide,  it  was  thought  by  myself  and  others  that  his  obsti- 
nate refusal  of  food  was  associated  with  ideas  of  self-destruction.  He  died,  and  at 
the  post-mortem  examination  a  stricture  in  the  pylorus  was  discovered.  These  illus- 
trations, and  they  could  easily  be  extended,  will  prove  the  importance  of  paying  minute 
attention  to  particular  delusions  with  the  view  of  ascertaining  whether  they  have  not 
a  particular  and  actual  physical  origin. 

The  prognosis  in  cases  of  insanity  will  mainly  depend  upon  the  duration  of  the 
attack,  its  character  and  origin,  and  the  diathesis  of  the  patient.  The  prognosis  is 
generally  unfavorable  if  the  disease  is  hereditary — if  the  symptoms  are  similar  in  char- 
acter to  those  exhibited  by  other  members  of  the  family  when  insane.  Insanity, 
accompanied  by  acute  excitement,  is,  ccBteris  paribus,  more  easy  of  cure  than  when 
it  has  been  of  slow  and  gradual  growth  and  is  marked  by  great  mental  depression. 
The  prognosis  is  favorable  in  cases  of  puerperal  mania ;  it  is  unfavorable  when  there 
exists  a  want  of  symmetry  between  the  two  sides  of  the  head,  with  small  anterior  and 
large  posterior  cerebral  development.  Any  great  inequality  in  the  cranial  conformation 
would  be  a  suspicious  indication.  The  existence  of  any  malformation  in  the  development 
of  the  chest  is  also  an  unfavorable  sign,  and  would  induce  us  to  give  a  guarded  prognosis. 
Dr.  Darwin  says,  when  a  person  becomes  insane  who  has  a  small  family  of  children  to 
absorb  his  attention,  his  prospect  of  recovery  is  but  small,  as  it  establishes  that  the  ma- 
niacal hallucination  is  more  powerful  than  those  ideas  which  usually  interest  us  most. 
The  prognosis  is  unfavorable  when  patients  are  under  the  morbid  delusion  that  they  are 
poisoned  and  are  constantly  suffering  internally  from  peculiar  sensations.  Religious  de- 
lusions are  more  difficult  to  eradicate  than  other  morbid  impressions.  The  age  of  the 
patient  will  materially  guide  us  in  forming  a  correct  prognosis.  Hippocrates  says  the 
insane  are  not  curable  after  the  fortieth  year ;  Esquirol  maintains  the  greater  portion 
recover  between  the  ages  of  twenty  and  thirty;  Haslam  between  the  ages  of  ten  and 
twenty.  As  a  principle,  we  may  conclude  that  the  probability  of  recovery  in  any  given 
case  is  in  proportion  to  the  early  age,  physical  condition,  and  duration  of  the  attack. 
When  a  patient  has  youth  and  a  good  constitution  to  aid  him,  and  is  advantageously 
placed,  having  at  command  remedial  measures,  and  is  excluded  from  all  irritating  cir- 
cumstances, the  prognosis  may  be  favorable.    I  have  seen  patients  after  the  advanced  age  of 


288  PSYCHOLOGICAL    MEDICINE. 

sixty  and  seventy  recover,  and  cases  of  cure  are  upon  record  where  insanity  has  existed 
for  ten,  fifteen,  and  twentj'  years.  In  forming  our  prognosis  it  is  important  to  ascertain  the 
educational  training  of  the  patient.  Has  he  been  in  the  habit  of  exercising  great  self- 
control  ?  Has  his  mind  been  well-disciplined  ?  Has  he  kept  in  abeyance  the  passions, 
or  have  the  motions  and  impulses  of  his  nature  obtained  the  mastery  over  him  ?  He 
who  has  been  taught  to  practice  self-denial  and  self-control  in  early  life  is,  ccBteris  pari- 
bus, in  a  more  favorable  position  for  recovery  than  he  who  has  permitted  himself  to  be 
the  willing  and  obedient  slave  of  every  passion  and  caprice.  Insanity  accompanied  with 
criminal  propensities  is  said  to  be  incurable,  because,  as  Ideler  urges,  such  patients  "  can- 
not bear  the  torments  of  their  consciences,  and  relapse  into  the  stupefaction  of  insanity 
to  flee  from  the  consciousness  of  their  guilt."  The  prognosis  is  unfavorable  when  the 
insanity  is  complicated  with  organic  disease  of  the  heart  and  lungs,  with  deafness,  and 
paralysis  in  any  of  its  forms.  Lesions  of  the  motor  power  are  very  unfavorable  indica- 
tions. Great  impairment  of  mind,  accompanied  with  delusions  of  an  exalted  character 
and  associated  with  paralysis,  is  generally  incurable.  Esquirol  says,  epilepsy,  if  asso- 
ciated with  insanity,  places  the  patient  beyond  all  prospect  of  cure.  I  should  be  loath  to 
adopt  this  sweeping  condemnation.  I  have  seen  cases  of  epilepsy,  combined  with  men- 
tal derangement,  recover,  although,  I  admit,  they  constitute  a  difficult  class  of  cases  to 
manage. —  Lancet,  October  8th,  1852,  p.  321. 

[As  it  would  be  impossible  to  describe  in  detail  the  particular  class  of  remedial  agents 
adapted  to  each  class  of  deranged  minds,  in  the  succeeding  lecture  the  subject  has  been 
generalized, — the  most  prominent  kinds  of  insanity,  and  the  difficulties  of  their  manage- 
ment, only  being  discussed.] 

In  regard  to  the  treatment  of  acute  mania,  the  importairi;  and  much-litigated  question 
at  issue  among  practitioners  of  all  countries,  is  that  relating  to  the  propriety  of  depletion. 
Need  I  direct  your  attention  to  the  conflicting  and  contradictory  opinions  entertained  by 
eminent  writers  on  this  important  and  much-vexed  therapeutical  point  ?  Whilst  some 
practitioners  of  great  repute  and  enlarged  experience  fearlessly  recommend  copious  gene- 
ral depletion  for  the  treatment  of  insanity,  and  refer  to  cases  in  which  this  practice  has 
been  attended  with  the  happiest  results,  others,  equally  eminent,  and  as  much  entitled  to 
our  respect,  denounce  the  lancet  as  a  most  fatally  dangerous  weapon,  and  shudder  at  the 
suggestion  of  abstracting,  even  locally,  the  smallest  quantity  of  blood.  In  avoiding  Scylla 
we  must  be  cautious  of  being  impelled  into  Charybdis.  The  error  consists  in  a  vain  effort 
to  discover  a  uniform  rule  of  treatment,  and  attempting  to  propound  some  specific  mode 
of  procedure  adapted  to  all  cases.  He  who  maintains  that  bloodletting  is  never  to  be 
adopted  in  the  treatment  of  mania,  without  reference  to  its  character,  its  origin,  the  pecu- 
liar constitution  of  the  patient,  and  the  existence  of  local  physical  morbid  conditions, 
which  may  be  materially  modifying  the  disease,  and  giving  active  development  to  delusive 
impressions,  is  not  a  safe  practitioner.  Neither  would  I  confide  in  the  judgment  of  the 
physician  who  would,  in  every  case  of  violent  maniacal  excitement,  attempt  to  tranquil- 
lize the  patient  by  either  general  or  local  depletion. 

In  attacks  of  insanity,  when  the  symptoms  are  acute,  the  patient  young  and  plethoric, 
the  habitual  secretions  suppressed,  the  head  hot  and  painful,  the  eyes  intolerant  of  light, 
the  conjunctiva  injected,  the  pupils  contracted,  the  pulse  rapid  and  hard,  and  the  parox- 
ysm sudden  in  its  development,  one  general  bleeding  will  often  arrest  the  progress  of  the 
cerebral  mischief,  greatly  facilitate  the  application  of  other  remedies,  and  ultimately  pro- 
mote recovery.  In  proportion  as  the  symptoms  of  ordinary  insanity  approach  those  of 
phrenitis,  shall  we  be  justified  in  the  use  of  general  depletion.  Although  it  is  only  occasion- 
ally, in  instances  presenting  peculiar  characteristic  features, — cases  occurring  in  the  higher 
ranks  of  life,  where  the  patient  has  been  in  the  habit  of  living  above  par,  and  is  of  a  san- 


LUNACY    IN    ENGLAND.  289 

guineous  temperament, — that  we  are  justified  in  having  recourse  to  the  lancet,  there  is  a 
large  class  of  recent  cases  presenting  themselves  in  the  asylums  for  the  insane,  both  pub- 
lic and  private,  in  the  treatment  of  which  we  should  be  guilty  of  culpable  and  cruel 
negligence,  if  we  were  to  omit  to  relieve  the  cerebral  symptoms  by  means  of  the  local 
abstraction  of  blood.  It  is,  alas  !  the  fashion  and  caprice  of  the  day  to  recklessly  decry 
the  application  of  cupping-glasses  or  of  leeches  in  the  treatment  of  insanity,  in  conse- 
quence, I  think,  of  the  slavish  deference  shown  to  the  opinion  of  a  few  French  patholo- 
gists of  eminence,  who  have,  by  their  indiscriminate  denunciation  of  all  depletion,  fright- 
ened us  into  submission,  and  compelled  us  to  do  violence  to  our  own  judgment.  The 
local  abstraction  of  blood  is,  in  the  hands  of  the  discreet  and  judicious  practitioner,  a 
powerful  curative  agent ;  and  yet  it  is  the  practice  of  some  men,  and  men,  too,  of  position, 
to  discard  altogether  the  remedy. 

I  will  briefly  refer  to  the  kind  of  case  in  which  the  local  abstraction  of  blood  will  be 
found  most  beneficial,  if  proper  regard  be  had  to  the  temperament,  constitutional  condition, 
and  the  local  circumstances  modifying  the  character  of  the  attack.  In  insanity,  when  the 
exacerbations  occur  at  the  menstrual  period,  cceteris  paribus,  leeches  to  the  vulva  and 
thighs,  with  the  use  of  foot-bath,  and  the  exhibition  of  aloetic  purgatives,  will  be  attended 
by  the  most  favorable  results.  In  irregular  and  obstructed  menstruation,  the  local  abstrac- 
tion of  blood  will  be  very  serviceable.  In  suppressed  haemorrhoids,  leeches  to  the  neigh- 
borhood of  the  sphincter  ani  will  greatly  benefit  in  unloading  the  hsemorrhoidal  vessels, 
and  relieve  the  brain  of  undue  excitement.  In  cases  of  nymphomania,  leeches  to  the 
vulva  are  indicated,  and  have  been  known  to  greatly  benefit.  In  cases  of  intermittent 
insanity,  the  paroxysm  may  often  be  cut  short  by  relieving  the  overloaded  state  of  the  ves- 
sels of  the  head  by  means  of  cupping  or  the  application  of  leeches.  In  some  instances, 
I  have  tried  Dr.  Wigan's  plan,  and  have  applied  leeches  to  the  Schneiderian  membrane, 
particularly  for  the  treatment  of  insanity  of  early  life,  and  connected  with  conduct  evi- 
dently the  effect  of  cerebral  irritation.  I  have  seen  this  mode  of  procedure  of  essential 
benefit  in  persons  of  plethoric  constitution  and  of  sanguineous  temperament.  Occasion- 
ally the  insanity  is  found  to  be  associated  with  active  visceral  disease,  or  with  hypertrophy 
and  other  affections  of  the  heart.  Under  these  circumstances,  when  there  exists  great 
tenderness  over  the  region  of  any  of  the  visceral  organs,  and  we  are  satisfied,  by  a  care- 
ful stethoscopic  examination,  that  hypertrophy  of  the  heart  is  present,  leeches  applied 
over  the  seat  of  the  local  mischief,  conjoined  with  other  appropriate  treatment,  will  ma- 
terially aid  us  in  subduing  the  maniacal  affection.  In  cases  of  illusions  of  hearing,  or  of 
vision,  it  will  often  be  necessary  to  apply -leeches  behind  the  ears,  or  over  the  superciliary 
ridges.  I  have  known  this  practice  entirely  remove  the  morbid  illusions  which  had  been 
embittering  the  person's  life. 

But  apart  entirely  from  the  local  affections  to  which  I  have  referred,  for  the  treatment  of 
idiopathic  insanity,  apparently  without  any  complications,  or  modified  by  any  of  the  associ- 
ated diseases,  the  careful  and  temperate  local  abstraction  of  blood,  when  general  depletion 
is  inadmissible,  will  often  materially  shorten  the  duration  of  an  attack  of  insanity,  and 
restore  the  mind  to  a  healthy  condition.  I  am  anxious  to  record  my  favorable  opinion  of 
this  mode  of  treatment,  because  I  have  witnessed  so  many  sad  results  from  an  opposite, 
timid,  and  reprehensible  neglect  of  the  means  placed  within  our  power  for  the  treatment 
of  the  varied  forms  and  degrees  of  mental  derangement.  Sad  consequences  have  un- 
doubtedly followed  the  indiscriminate  use  of  depletory  measures ;  the  presence  of  violent 
mental  excitement  has  occasionally  led  the  practitioner  to  the  conclusion  that  the  disease 
was  of  an  active  character ;  and  in  the  attempt  to  allay  the  undue  cerebral  excitement 
by  means  of  antiphlogistic  measures,  the  patient  has  sunk  into  incurable  and  hopeless  de- 

19 


290  PSYCHOLOGICAL    MEDICINE. 

mentia.  But  recognizing  an  an<zmic  class  of  cases,  where  great  excitement  is  often  asso- 
ciated with  loss  of  nervous  and  vital  power,  we  must  be  cautious  in  permitting  serious 
disease  to  be  creeping  stealthily  on  in  the  brain,  no  effort  being  made  to  relieve  the  con- 
gested cerebral  vessels  or  inflamed  tissue,  until  serious  disorganization  has  taken  place  in 
the  delicate  structure  of  the  vesicular  matter,  and  the  patient  is  forever  lost.  In  the  treat- 
ment of  acute  mania,  the  remedy  next  in  importance  to  cautious  depletion  is  that  of  p7-o- 
longed  hot  baths.  To  Dr.  Brierre  de  Boismont,  of  Paris,  at  whose  excellent  institution  I 
first  witnessed  the  application  of  this  remedial  agent,  the  profession  is  indebted  for  reviv- 
ing a  practice  which  had  long  fallen  into  disrepute.  In  treatment  of  acute  mania,  the 
prolonged  hot  baths  will  be  found  of  the  most  essential  service.  Dr.  Brierre  de  Boismont 
has  recorded  the  history  of  sixty-one  of  seventy  two  cases  that  were  subjected  to  this 
mode  of  treatment.  Three-fourths  of  this  number  were  cured  in  a  week,  and  the  remain- 
der in  a  fortnight.  The  patients  remain  from  eight  to  ten  and  fifteen  hours  in  warm  baths, 
whilst  a  current  of  cold  water  is  continually  poured  over  the  head;  the  temperature  of 
these  baths  is  from  82°  to  86°  Fahr. ;  the  affusions  60°  Fahr.  Among  the  therapeutic 
effects  of  these  baths,  Dr.  B.  de  Boismont  reckons  a  diminution  of  the  circulation  and 
respiration,  relaxation  of  the  skin,  alleviation  of  thirst,  the  introduction  of  a  considerable 
quantity  of  water  into  the  economy,  an  abundant  discharge  of  limpid  urine,  a  tendency 
to  sleep,  a  state  of  repose.  This  mode  of  treatment  is  said  to  be  ineffectual  in  cases  of 
periodic  intermittent  mania,  in  mania  beginning  with  great  mental  impairment,  or  asso- 
ciated with  epilepsy  or  general  paralysis.  The  result  of  my  own  experience  of  this  plan 
of  treatment  has  produced  a  very  favorable  impression  upon  my  mind,  and  I  think  it  is 
entitled  to  a  fair  trial  in  all  our  public  asylums  where  they  admit  acute  and  recent  cases. 

In  some  forms  of  acute  mania  it  is  desirable,  as  a  substitute  for  depletion,  to  diminish 
the  activity  of  the  circulation  by  the  exhibition  of  nauseating  doses  of  the  tartrate  of  an- 
timony; it  maybe  serviceably  combined  with  the  tinctures  of  digitalis  and  hyoscyamus. 
This  remedy,  however,  requires  careful  watching,  as  it  often  has  been  known  to  suddenly 
reduce  the  vital  powers  to  a  low  ebb,  and  extinguish  life.  It  will  be  found  beneficial  in 
proportion  to  the  recent  character  of  the  case,  and  the  positive  activity  of  the  cerebral 
circulation.  The  tincture  of  digitalis  was  formerly  in  great  repute  as  an  anti-maniacal 
remedy ;  the  experience  of  late  years  has  not  encouraged  us  in  administering  it  in  the 
doses  prescribed  by  some  of  the  old  writers;  nevertheless,  it  is  a  useful  agent,  and  occa- 
sionally proves  a  valuable  auxiliary  in  the  hand  of  the  practitioner  who  carefully  watches 
its  operation. 

For  the  cure  of  the  acute  forms  of  insanity  the  douche  bath  has  been  much  lauded ; 
but  this  remedy  is  now  rarely  used  in  British  asylums.  I  have  occasionally  seen  benefit 
derived  from  its  exhibition,  but  it  requires  great  caution  in  its  use.  A  patient  has  been 
subjected,  whilst  in  a  paroxysm  of  acute  delirium,  to  the  douche  bath,  and  has  sunk  almost 
immediately  into  incurable  idiocy !  The  physical  shock  has  occasionally  been  known  to 
produce  a  good  moral  impression.  For  illustration  :  a  patient  imagined  himself  emperor 
of  the  world,  and  would  not  allow  any  one  to  address  him  by  any  other  title.  The  im- 
mediate application  of  the  douche  bath  destroyed  his  idea  of  royal  dignity,  and  he  was 
willing  to  admit  that  he  had  never  been,  nor  was  at  any  time  a  regal  personage.  A 
few  hours  subsequently  the  delusive  impression  returned  in  all  its  original  force ;  the 
douche  bath  was  again  had  recourse  to,  and  a  second  time  the  morbid  impression  van- 
ished ;  by  a  series  of  baths  he  was  restored  to  sanity,  and  after  his  complete  recovery, 
when  the  particulars  of  his  case  were  placed  before  him,  he  observed,  "  Why  did  you 
not  whip  me,  and  beat  this  nonsense  out  of  my  head  ?  I  wonder  how  you  could  have 
borne  with  my  folly,  or  I  have  been  guilty  of  such  contemptible  arrogance  and  obsti- 


LUNACY    IN    ENGLAND.  29 I 

nacy."  As  a  substitute  for  the  douche,  the  shower  bath  is  often  used  with  great  benefit, 
particularly  in  certain  forms  of  melancholia,  associated  with  nervous  depression  and 
general  debility.  In  cases  of  melancholia,  or  other  kinds  of  chronic  insanity  connected 
with  a  congested  state  of  the  liver,  the  nitro-rauriatic  bath  will  occasionally  do  much 
good.  In  a  few  instances  I  have  noticed  marked  benefit  from  Bertolini's  sedative  bath, 
composed  of  henbane  two  pounds,  and  equal  parts  of  hemlock,  and  cherry-laurel  leaves, 
well  infused  in  a  sufficient  quantity  of  hot  water.  But  the  .simple  hot  bath  in  certain 
conditions  of  the  nervous  system,  particularly  in  some  forms  of  suicidal  mania,  is  of  the 
utmost  benefit.  A  warm  bath  a  short  period  before  retiring  to  rest,  bathing  the  head  at 
the  same  time  with  cold  water,  particularly  if  the  scalp  be  unnaturally  hot,  will  often 
insure  a  quiet  and  composed  night,  when  no  description  of  sedative,  however  potent  its 
character  and  dose,  would  influence  the  system. 

In  the  early  stages  of  insanity,  and  throughout  its  whole  course,  the  bowels  are  often 
in  an  obstinately  constipated  condition.  The  concentration  of  nervous  energy  in  the 
brain  appears  to  interfere  with  that  supply  which  should  proceed  to  other  structures  ;  con- 
sequently there  appears  to  be  a  want  of  healthy  sensibility  in  the  mucous  membrane  of 
the  bowels,  and  an  interruption  to  the  peristaltic  action  of  the  intestinal  canal.  There 
is  no  class  of  agents  which  act  so  certainly  and  effectually  in  relieving  the  mind  when 
under  the  influence  of  depressing  emotion,  as  cathartics.  The  ancients  considered  helle- 
bore as  a  specific  in  certain  forms  of  melancholia.  In  the  hands  of  modern  practition- 
ers it  has  not  been  found  to  merit  the  high  encomiums  which  have  been  passed  upon  it. 
It  is  important  in  every  case  of  insanity,  but  particularly  in  the  acute  stages  of  mental 
derangement,  to  act  powerfully  upon  the  bowels  by  means  of  a  succession  of  brisk  ca- 
thartics. The  bowels  are  often  found  gorged  with  fecal  matter,  and  immediate  relief 
often  follows  the  administration  of  two  or  three  doses  of  calomel  and  colocynth,  or  of 
croton-oil.  It  will  often  be  necessary  to  assist  the  operation  of  the  cathartics  by  means 
of  enemata.  In  hysterical  and  some  other  forms  of  insanity  there  is  always  a  disposition 
on  the  part  of  the  patient  i-esolutely  to  resist  the  calls  of  nature,  and,  knowing  this  pecu- 
liarity, we  must  carefully  watch  the  condition  of  the  bowels,  otherwise  serious  mechani- 
cal obstructions  may  ensue,  followed  by  intractable  diseases  of  the  rectum.  Insanity  is 
often  associated  with  gastric  and  intestinal  disease,  with  an  irritable  condition  of  the 
mucous  membrane  of  the  alimentary  canal;  and,  in  such  cases,  although  it  is  important 
to  relieve  the  bowels  and  prevent  them  from  being  constipated,  we  must  bear  in  mind 
that  the  injudicious  exhibition  of  irritating  drastic  cathartics  may  aggravate  the  mental 
disease,  by  increasing  the  gastric  and  intestinal  irritation,  and  thus  do  permanent  and 
irremediable  mischief.  Much  injury  may  arise  from  the  indiscriminate  and  injudicious 
administration  of  cathartics.  In  insanity  associated  with  menstrual  obstructions,  it  will 
be  necessary  to  exhibit  the  class  of  purgatives  known  to  act  specifically  upon  the  lower 
bowel ;  consequently  aloetic  cathartics,  such  as  the  compound  decoction  of  aloes,  are 
found  of  most  service  in  these  cases.  In  plethoric  habits,  when  there  is  a  marked  deter- 
mination of  blood  to  the  head,  no  medicine  will  relieve  so  speedily  as  active  doses  of  the 
compound  powder  of  jalap. 

In  the  treatment  of  insanity,  the  class  of  medicines  termed  sedative  play  an  important 
part.  If  exhibited  with  judgment,  the  most  gratifying  results  often  follow  their  contin- 
uous and  persevering  administration.  The  sedative  treatment  of  insanity  is  a  subject  of 
itself,  and  I  quite  despair  of  touching  even  upon  the  confines  of  many  interesting  and 
important  points  involved  in  the  consideration  of  this  division  of  my  lecture.  In  insanity 
unassociated  with  active  cerebral  circulation,  congestion,  or  paralysis,  or  after  the  head 
symptoms  have  been  relieved  by  the  local  abstraction  of  blood  and  the  administration  of 


292  PSYCHOLOGICAL   MEDICINE. 

appropriate  medicine,  the  exhibition  of  sedatives  will  be  followed  by  the  most  beneficial 
results.  In  recent  cases  they  are  generally  inadmissible,  except  in  delirium  tremens  and 
puerperal  insanity,  and  other  forms  of  derangement  analogous  in  their  pathological  char- 
acter and  symptoms  to  these  affections.  In  chronic  insanity,  in  melancholia  unconnected 
with  abdominal  repletion,  or  visceral  disease,  the  persevering  use  of  sedatives  in  various 
combinations  will  often  re-establish  sanity,  when  no  other  course  of  treatment  is  likely 
to  be  successful  in  dispelling  the  illusive  impressions,  or  raising  the  drooping  and  de- 
sponding spirits.  Battley's  solution,  the  tincture  of  opium,  the  meconite,  acetate,  and 
hydrochlorate  of  morphia,  the  preparations  of  hyoscyamus,  conium,  stramonium,  cam- 
phor, hops,  aconite,  ether,  chlorofonn,  hydrocyanic  acid,  Indian  hemp,  are  all  of  great 
and  essential  service  if  administered  with  judgment  and  sagacity.  In  suicidal  insanity, 
when  local  cerebral  congestion  is  absent,  and  the  general  health  and  secretions  are  in 
good  condition,  the  meconite  and  hydrochlorate  of  morphia  often  act  like  a  charm,  unin- 
terruptedly and  ■[>erseve7-ingly  given  until  the  nervous  system  is  completely  under  its  influ- 
ence. I  have  witnessed  the  most  distressing  attacks  of  suicidal  mania  yield  to  this  treat- 
ment, when  ever)'  other  system  has  failed.  I  could  cite  the  particulars  of  numerous  cases 
of  this  form  of  insanity  radically  cured  by  the  occasional  local  abstraction  of  blood  from 
the  head,  the  administration  of  alteratives,  the  warm  bath,  and  sedatives.  In  the  use  of 
this  powerful  curative  agent,  our  success  will  often  depend  upon  a  ready  adaptation  of  the 
kind  of  sedative  to  the  descriptio7i  of  case  in  which  it  may  be  deeified  admissible,  and  a 
judicious  combination  of  various  kinds  of  sedatives.  I  do  not  think  we  pay  sufficient 
attention  to  such  combinations.  I  have  often  seen  an  apparently  incurable  and  unman- 
ageable case  yield  to  several  kinds  of  sedatives  combined,  when  it  resisted  the  operation 
of  any  one  or  two.  The  extract  of  conium  is  often  of  service  in  cases  of  insanity  com- 
bined with  epilepsy;  conjoined  with  mineral  tonics,  conium  is  occasionally  of  benefit, 
particularly  in  melancholia  connected  with  chronic  diseases  of  the  digestive  organs  and 
with  neuralgia.  In  cases  of  uterine  irritation,  I  have  seen  great  good  result  from  the 
combination  of  hops,  camphor,  and  hyoscyamus.  In  illusions  of  vision,  belladonna, 
commencing  with  quarter-grain  doses,  will  be  found  a  useful  remedy.  In  insanity 
complicated  with  dysmenorrhoea,  the  combination  of  camphor  with  hyoscyamus,  opium 
or  conium,  may  be  given  with  great  advantage.  The  hydrochlorate  of  morphia, 
in  union  with  dilute  hydrochloric  acid,  is  said  to  be  useful  in  cases  where  the  seda- 
tive treatment  is  desirable.  I  am  often  in  the  habit  of  exhibiting  sedatives  and  tonics 
in  a  state  of  combination,  particularly  conium  with  iron,  opium  with  quinine,  or  with 
the  infusion  or  compound  decoction  of  cinchona.  In  debility,  with  irritability  of  the 
nervous  system,  accompanied  by  restlessness,  Battley's  solution,  with  the  preparations 
of  cinchona,  will  often  prove  of  great  benefit.  The  tincture  of  sumbul  I  have  occasion- 
ally administered,  and  I  think  with  advantage,  in  paroxysmal  or  convulsive  forms  of  in- 
sanity. I  have  given  to  the  extent  of  one  or  two  drachms  for  a  dose.  In  hysterical  de- 
rangement, the  tincture  of  Indian  hemp  will  occasionally  allay  the  excitement,  and 
produce  sleep  more  rapidly  than  any  other  form  of  sedative.  The  valerianate  of  zinc  has 
not  answered  the  expectations  of  those  who  have  spoken  so  highly  of  its  medicinal  vir- 
tues. Tincture  of  opium  with  camphor,  and  the  tartrate  of  antimony,  is  an  excellent  com- 
bination in  cases  of  doubtful  cerebral  congestion.  Tincture  of  hops,  in  doses  of  from  one 
to  four  drachms,  it  will  be  necessary  to  give  when  no  other  formulae  are  admissible.  As 
a  mild  form  of  sedative,  compound  ipecacuanha  powder  is  occasionally  recommended; 
but  a  good  substitute  for  Dover's  powder  is  a  pill  composed  of  opium,  ipecacuanha,  and 
soap. 

In  treating  the  more  chronic  forms  of  insanity,  particularly  melancholia,  it  will  be  es- 


LUNACY    IN    ENGLAND.  293 

sential  to  bear  in  mind  that  they  are  difficult  of  cure,  because,  owing  to  the  slow,  obscure 
and  insidious  character  of  the  disease,  the  mental  affection  has  been  of  some  duration 
before  the  attention  of  the  practitioner  has  been  directed  to  its  existence.  As  this  form 
of  derangement  generally  exhibits  itself  in  trifling  perversions  of  the  affections  and  pro- 
pensities, leading  to  little  acts  of  extravagance  and  irregularity  of  conduct,  associated 
with  great  depression,  we  often  find  the  attack  has  existed  some  years  before  a  necessity 
is  felt  for  any  medical  advice  or  treatment— perhaps  a  suicidal  propensity  has  manifested 
itself,  this  being  the  first  apparent  overt  act  of  the  insanity. 

It  is  necessary,  before  suggesting  any  course  of  treatment  in  melancholia,  to  ascertain 
whether  any  latent  visceral  disease  be  present.  Occasionally  the  local  irritation  will  be 
found  either  in  the  liver,  or  the  stomach  and  bowels,  and  in  women  the  uterine  functions 
are  frequently  disordered.  In  the  religious  and  other  forms  of  melancholia  in  females, 
the  delusive  ideas  are  often  associated  with  uterine  irritation ;  and  under  such  cir- 
cumstances, if  actual  physical  derangement  of  an  active  character  exists  in  this  organ, 
the  best  treatment  will  be,  the  application  of  leeches  to  the  neighborhood  of  the  uterus, 
combined  with  warm  hip-baths,  sedatives  and  mineral  tonics.  In  cases  of  melancholia, 
the  digestive  functions  are  often  much  vitiated,  the  circulation  languid,  the  skin  cold  and 
flaccid ;  and  these  symptoms  being  conjoined  with  a  general  loss  of  physical  tone,  such 
patients  require  generous  diet,  good  air,  gentle  exercise,  and  occasional  stimuli.  When 
dyspeptic  symptoms  are  combined  with  an  inactive  state  of  the  bowels,  I  have  often  ad- 
ministered the  compound  tincture  of  guaiacum  with  great  benefit.  It  is  important  to 
watch  the  particular  features  in  these  cases,  and  to  improve  the  general  health  by  the  ex- 
hibition of  mild  alteratives  and  vegetable  tonics,  with  alkalies.  I  have  occasionally  ad- 
ministered, with  success,  in  this  form  of  insanity,  apparently  associated  with  an  abnor- 
mal condition  of  the  nutrition  of  the  brain,  cod-liver  oil,  with  preparations  of  iron. 

My  time  will  not  admit  of  my  submitting  for  your  approval  the  treatment  best  adapted 
for  those  forms  of  mental  disease  associated  with  an  atrophied  or  softened  condition  of  the 
nervous  matter.  I  think  more  is  to  be  done  for  the  cure  of  these  cases  than  the  writings 
of  medical  men  would  lead  the  student  to  suppose,  particularly  if  the  disease  be  seen  and 
subjected  to  treatment  in  the  early  stages.  I  have  recorded  the  details  of  several  instances 
of  cerebral  disease,  exhibiting  all  the  legitimate  features  of  ramollissement,  and  yield- 
ing to  the  persevering  administration  of  the  preparations  of  iron,  phosphorus,  zinc  and 
strychnia,  combined  with  generous  living,  and  the  occasional  application  of  a  leech  behind 
the  ear,  should  indications  of  cerebral  congestion  be  present.  I  have  also  derived  benefit  in 
these  cases  from  the  use  of  the  milder  forms  of  mercury,  associated  with  cinchona.  In  cases 
of  impairment  of  the  mind,  loss  of  memory,  defective  power  of  attention,  occasional  par- 
oxysms of  mental  paralysis,  unconnected  with  lesions  of  the  motor  power,  I  have  found 
a  solution  of  the  acetate  of  strychnine,  and  a  solution  of  the  phosphate  of  strychnine,  of 
great  advantage. 

In  some  chronic  forms  of  insanity,  in  dementia,  and  persistent  monomania,  connected, 
as  it  was  supposed,  with  morbid  thickening  of  the  dura  mater,  and  with  interstitial  infiltra- 
tion of  the  membranes,  as  well  as  with  exudations  upon  its  surface,  I  have  occasionally 
had  the  head  shaved,  and  have  perseveringly  rubbed  over  the  scalp  a  strong  ointment  of 
the  iodide  of  potassium  combined  with  strychnine.  In  other  instances  I  have  kept  the 
head  painted  with  the  mixture  of  iodine.  I  have  seen  marked  benefit  from  this  mode  of 
treatment.  In  several  cases  where  the  mental  symptoms  were  supposed  to  be  associated 
with  effusions  of  serum,  I  have  ordered  the  iodine  to  be  applied  externally,  at  the 
same  time  exhibiting  minute  doses  of  calomel,  or  mercury  with- chalk,  to  slightly  affect 
the  system ;  this,  conjoined  with  occasional  tonics,  diuretics,  and  stimuli  to  support  the 


294  PSYCHOLOGICAL    MEDICINE. 

vital  powers  and  enable  the  patient  to  undergo  this  treatment,  is  occasionally  productive 
of  considerable  benefit,  in  cases  apparently  placed  quite  beyond  the  reach  of  improvement 
or  cure. 

I  have  only  briefly  spoken  of  two  distressing  and  often  unmanageable  forms  of  insan- 
ity— viz.,  of  suicidal  mania,  and  of  those  cases  where  the  patient  obstinately  refuses  to 
take  either  food  or  medicine.  In  insanity  associated  with  suicidal  tendencies,  it  will  be 
important  to  ascertain  whether  any  cerebral  congestion  exist,  as  such  is  often  the  case. 
A  few  leeches  applied  to  the  head,  followed  by  an  active  cathartic,  will  relieve  the  local 
irritation,  and  often  dissipate  the  idea  of  self-destruction.  In  the  absence  of  any  posi- 
tive active  cerebral  symptoms,  the  prolonged  hot  bath,  and  the  persevering  exhibition  of 
some  form  of  sedative,  is  the  best  treatment  to  be  adopted.  I  have  seen  the  suicidal 
impulse  removed  after  the  administration  of  a  few  doses  of  belladonna ;  but  the  meconile 
and  hydrochlorate  of  morphia,  if  given  for  a  sufficient  length  of  time,  will,  in  the  great 
majority  of  cases,  distinct  from  actual  incurable  visceral  or  cerebral  disease,  effect  a  cure. 
Occasionally  the  shower-bath,  and  counter-irritation  in  the  vicinit)'  of  the  head,  will  aid 
us  in  re-establishing  health.  Cases  sometimes  present  themselves  where  the  patient  de- 
terminately  refuses  to  take  either  food  or  medicine.  This  character  of  case  gives  those 
who  have  the  care  of  the  insane  much  anxiety.  The  refusal  of  food  may  be  connected 
with  the  determination  to  destroy  life,  or  it  may  be  associated  with  delusive  impressions. 
I  am  inclined  to  believe  that  in  the  majority  of  these  cases  the  symptom  is  the  result  of 
some  local  mischief  remote  from  the  brain,  and  sympathetically  affecting  the  organ  of 
thought.  Upon  examination  we  often  find,  in  these  cases,  great  gastric  derangement, 
obstinate  constipation,  considerable  tenderness  upon  pressure  in  the  epigastric  region, 
hepatic  disease,  the  tongue  foul,  breath  offensive,  and  other  symptoms  of  derangement  of 
the  chylopoietic  viscera.  The  determination  to  resist  nourishment  arises,  under  such  cir- 
cumstances, irom^  a.  positive  loathing  of  food — a  want  of  all  inclination  for  it.  I  have 
seen  cases  of  this  description,  where  it  has  been  deemed  necessary,  in  order  to  prolong 
life,  to  introduce  food  forcibly  into  the  stomach,  speedily  cured  by  the  adoption  of  means 
for  improving  the  state  of  the  general  health  and  digestive  organs.  Mild  alteratives,  vege- 
table tonics,  blisters  over  the  region  of  the  stomach,  if  the  patient  complains  of  pain  in 
that  region  upon  pressure,  the  warm  and  shower-bath, — is  the  most  successful  treatment 
to  adopt  in  cases  connected  with  obvious  visceral  derangement.  Instances  sometimes 
occur,  where  the  refusal  of  food  is  clearly  traceable  to  a  delusive  impression — an  halluci- 
nation of  taste,  which  makes  eveiything  appear  to  the  patient  bitter,  disgusting  and  poi- 
sonous. The  unhappy  patient  imagines  that  he  is  commanded,  either  by  good  or  evil 
spirits,  not  to  eat.  These  unhappy  persons  must  be  treated  upon  general  principles,  and 
the  remedies  be  adapted  to  the  peculiar  character  of  each  individual  case.  Under  such 
hallucinations  of  taste,  patients  often  swallow  the  most  extraordinarj'  articles.  The  case  of 
a  lunatic  is  recorded,  who  imagined  that  his  stomach  required  to  be  strengthened  with 
iron.  He  was  seized  with  inflammation  of  the  oesophagus  of  which  he  nearly  died.  He 
then  confessed  that  he  had  swallowed  the  blade  of  a  knife.  After  his  death,  there  were 
found  in  his  stomach  seven  oxidated  lath  nails,  each  two  inches  and  a  half  long ;  thirty- 
three  nails,  two  inches  long ;  forty-nine  smaller  iron  nails  and  rivets ;  three  pieces  of 
wound-up  iron  wire ;  an  iron  screw,  an  inch  long  ;  a  brass  image  of  a  saint ;  part  of  the 
blade  of  a  knife ;  and  other  articles,  amounting  in  number  to  lOO,  and  weighing  about 
twenty  ounces.  It  will  be  necessary,  in  cases  like  those  to  which  I  have  been  referring, 
to  ascertain  whether  the  determination  not  to  eat  is  the  eftect  of  such  perversion  or  hal- 
lucination of  taste. 

The  time  will  only  admit  of  my  alluding  generally  to  the  importance,  as  a  principle  of 


LUNACY    IN    ENGLAND.  295 

treatment,  of  the  administration  of  tonic  remedies,  active  exercise  in  the  open  air,  and 
to  good  and  generous  living.  It  is  rarely  necessary,  in  the  treatment  of  insanity,  to  de- 
prive the  patient  of  animal  food.  Individual  cases  occasionally  come  under  our  notice, 
in  which  it  is  necessary,  for  a  time,  to  enforce  a  farinaceous  diet;  but  such  is  not  often 
our  duty.  Among  paupers,  insanity  is  frequently  cured  by  the  free  use  of  good  animal 
food,  and  a  generous  supply  of  porter.  Even  when  we  are  satisfied  of  the  necessity 
of  local  depletion,  it  will  often  be  necessary  to  give  wine,  and  allow  the  patient  a  gener- 
ous diet. 

There  are  many  other  essential  points  in  connection  with  this  important,  this  vast  sub- 
ject, which  I  am  reluctantly  compelled  to  pass  entirely  over.  When  I  had  resolved  to 
bring  this  matter  before  the  profession,  I  quite  despaired,  in  the  time  allotted  for  one  lec- 
ture, of  being  able  to  skim  even  upon  the  surface  of  the  many  deeply  interesting  points 
involved  in  the  inquiry ;  but  feeling — deeply,  earnestly  feeling — that,  in  relation  to  my 
own  specialty,  the  subject  of  the  medical  treatment  of  'insanity  was  of  the  first  moment, 
of  the  most  vital  importance  to  the  profession  as  well  as  to  the  public,  I  did  not  hesitate 
in  selecting  this  topic  for  one  of  my  lectures,  feeling  assured  that  you  would  kindly  make 
allowance  for  all  imperfections,  and  generously  appreciate  the  difficulties  I  had  to  en- 
counter in  concentrating  in  one  short  lecture  a  faint  glimpse  or  shadow  of  a  subject  re- 
quiring, for  its  successful  exposition,  nine  or  ten  lectures,  equal  in  length  to  the  one  I  have 
had  the  honor  of  reading  this  evening.  I  may  have  formed  an  extravagant  and  exaggerated 
conception  of  this  subject,  but  I  cannot  close  my  eyes  to  the  fatal  consequences  which 
have  so  often  ensued  from  a  belief  in  the  incurability  of  insanity  by  medical  means.  In 
all  grades  of  society,  we  witness  the  pernicious,  the  fatal,  the  disastrous  effects  of  this 
dogma.  We  see  it  influencing  the  conduct  of  county  magistrates  in  the  architectural  pro- 
portions, medical  organization,  and  general  arrangements  of  our  great  national  asylums. 
We  also  perceive  the  consequences  of  the  error  operating  in  many  of  the  private  institu- 
tions for  the  treatment  of  the  insane.  Alas  !  are  we  not  compelled  to  confess  that  many 
of  the  asylums  for  the  insane  constitute  mere  places  of  detention, — model  prisons, — and 
not  what  Government  ought  to  insist  upon  making  them — hospitals  for  the  cure  of  the  in- 
sane, under  the  government  of  medical  officers,  well  trained  by  preliminary  education, 
for  their  important  vocation,  acquainted  with  the  philosophy  of  the  human  mind,  and 
fitted  by  the  character  of  their  heart,  as  M'ell  as  by  their  intellect,  for  the  right  perform- 
ance of  the  solemn  and  responsible  duties  intrusted  to  them  by  the  public  and  the 
legislature  ? 


296  PSVCHOLOGICAL   MEDICINE. 


CHAPTER  XVI. 

THE  NECESSITY  FOR  A  NEW  METHOD  OF  INTRODUCING  EXPERT  TES- 
TIMONY IN  CRIMINAL  TRIALS,  WHERE  INSANITY  IS  ALLEGED  AS 
A    DEFENCE. 

It  would  be  a  reform  in  our  laws  relating  to  insanity,  if  New 
York,  and  other  States  likewise,  could  be  divided  into  four  or  more 
districts,  and  a  physician  in  lunacy  appointed  for  each  district  by 
the  governor.  This  board  of  physicians,  who  should  be  experts  or 
specialists  in  nervous  and  mental  diseases,  should  constitute  a  State 
lunacy  commission,  to  visit  and  report  as  to  the  condition  of  luna- 
tic hospitals,  to  protect  the  rights  of  those  who  are  incarcerated  in 
public  asylums,  and  also  strongly  support  the  medical  superinten- 
dents, who,  as  a  rule,  exhibit  skill  and  wisdom  of  the  highest 
order.  The  public  would  feel  more  assured,  perhaps,  that  no 
evils  or  abuses  could  spring  up  in  our  asylums,  and  also  that,  if 
there  is  any  room  for  improvement,  it  will  be  immediately  seen  by 
the  commissioners  in  lunacy,  if  it  escapes  the  superintendent's  eye. 
The  Lunacy  Commission  of  Great  Britain  has  been  of  great  benefit, 
both  to  the  officers  and  the  patients  of  the  English  institutions,  and  it 
would,  I  think,  be  the  same  in  our  own  country,  and  would  dispel 
the  prejudice  existing  against  our  asylums  and  their  managers. 

As  there  is  a  much-needed  reform  as  to  a  new  method  of  intro- 
ducing expert  testimony  in  criminal  trials  where  insanity  is  alleged 
,as  a  defence,  this  same  lunacy  commission  of  experts  might  be  of 
great  value  in  examining  such  cases  and  giving  testimony  upon  such 
trials.;  it  having  been  provided  in  the  statute  by  which  such  com- 
mission should  be  established,  that  the  counsel  for  the  prisoner,  in 
whose  behalf  the  plea  of  insanity  is  proposed  to  be  brought  forward, 
should  be  compelled  to  notify  such  board  of  such  proposed  plea» 
This  board  of  experts  should  have  every  facility  accorded  to  them, 
and  should  then  examine  the  prisoner's  mental  state,  discuss  the  ques- 
tion, make  their  conclusions,  and  should  take  written  memoranda  of 
such  examination.  They  then  should  appear  in  court  at  the  trial  to 
testify  as  to  the  prisoner's  sanity,  or  irresponsibility  if  they  find  him 
insane,  give  their  written  memoranda  of  the  prisoner's  examination, 
and  of  their  opinion  of  the  state  of  the  prisoner's  intellect  and  emo- 


EXPERT    TESTIMONY    IN    CRIMINAL   TRIALS.  29/ 

tions,  the  nature  of  the  mental  disorder  and  its  amount,  and  whether 
and  in  what  degree  the  mental  disorder  has  existed  at  the  period 
when  the  crime  was  committed.  In  submitting  a  written  statement 
by  the  experts,  we  secure  a  calm  and  impartial  statement,  which 
may  be  supplemented  in  court  afterwards,  by  questions  by  the  judge 
and  counsel.  This  board  of  experts  should  have  full  power  to  cause 
the  temporary  removal  of  the  prisoner  to  an  asylum,  so  as  to  have 
every  opportunity  for  his  examination  between  the  time  of  his  arrest 
and  the  trial. 

If  this  board  of  experts  decide  that  the  prisoner  is  insane,  the  judge 
and  jury  at  the  trial  would  doubtless  accept  their  verdict  as  final, 
and  the  prisoner  would  then  be  remanded  to  an  asylum,  and  in  such 
cases  as  Guiteau's,  to  an  asylum  for  the  chronic  insane  (as  such 
cases  are  incurable),  there  to  remain  for  life,  or  in  cases  of  ordinary 
insanity,  until  a  competent  superintendent  aided  by  the  lunacy  com- 
mission unanimously  pronounced  him  recovered. 

I  consider  that  this  would  be  a  very  important  medico-legal  reform, 
as  it  would  place  rich  and  poor  alike  on  the  same  footing  if  they 
were  on  trial  for  their  lives,  accused  of  murder.  Of  course  both 
prosecution  and  defence  could  call  in  otJier  experts  as  now,  if  thought 
best,  but  this  lunacy  commission  report  would  be  entirely  impartial, 
and  the  public  would  know  it  to  be  so.  All  the  factors  tending  to 
the  commission  of  crime  would  be  attentively  weighed,  and  certain 
penalties  would  not  be  inflicted  on  the  unhappy  victim  of  a  diseased 
imagination.  Dr.  D.  Hack  Tuke  of  England,  the  eminent  alienist, 
wisely  says:  "Infliction  of  punishment  must  depend  upon  accoun- 
tability, and  accountability  <upon  free  will,  and  free  will  upon  sanity. 
What  we  want  to  ascertain  is  not  the  mere  knowledge  of  right  and 
wrong,  but  whether  the  power  to  avoid  doing  wrong  was  sufficiently 
intact  to  involve  responsibility.  In  the  first  place,  I  think  that  the 
magistrate  before  whom  a  criminal  case  is  brought,  should,  if  there 
is  any  question  raised  as  to  the  prisoner's  sanity,  be  obliged  to 
order  an  examination  of  the  prisoner,  either  by  two  mental  experts  or 
one  expert  and  the  jail  surgeon.  The  obvious  advantage  here,  is 
that  we  obtain  the  best  opinion  we  can  secure  immediately  after  the 
crime  has  been  committed.  These  experts  should  have  full  power 
to  cause  the  temporary  removal  of  the  accused  to  an  asylum,  so  as 
to  have  every  opportunity  for  his  examination,  between  his  commit- 
tal and  his  trial  at  the  assizes.  If  they  regard  him  as  insane,  they 
should  be  employed  to  sign  the  certificate  now  required  by  the  27th 


298  PSYCHOLOGICAL    MEDICINE. 

and  28th  Vict.,  c.  29,  s.  2,  when  a  prisoner  in  custody  awaiting  his 
trial  is  removed  to  an  asylum.  At  the  trial,  the  jury  should,  as  at 
present,  decide  whether  the  accused  is  in  a  condition  to  plead,  after 
hearing  the  opinion  of  the  experts.  If  judged  unable  to  plead,  the 
prisoner  would  be  confined  in  the  criminal  asylum  under  the  same 
conditions  as  now.  If  considered  able  to  plead,  a  full  written  report 
drawn  up  by  the  experts  should  be  given  in  evidence.  If  the  court 
wishes  for  any  explanation  of  the  report,  the  experts  should  be  called 
into  the  witness  box." 

The  following  law  as  to  mental  responsibility  in  Austria,  extracted 
from  the  criminal  code,  is  very  precise  and  well  conceived  and  most 
excellent :  "  If  doubts  exist  whether  the  accused  possesses  the  use 
of  his  reason,  or  whether  he  suffers  from  an  affection  of  the  mind  by 
which  his  accountability  may  be  lost,  then  must  an  inquiry  into  the 
state  of  his  intellect  and  emotions  by  means  of  two  physicians  be  al- 
ways ordered.  These  have  to  make  their  report  of  the  result  of  their 
observations.  They  have  to  put  together  all  the  facts  influencing 
their  judgment  of  the  intellectual  and  emotional  condition  of  the  ac- 
cused. They  must  examine  them  according  to  their  importance, 
both  separately  and  when  taken  together,  and  if  they  consider  that 
there  exists  a  derangement  of  the  mind,  they  must  determine  the  na- 
ture of  the  disease,  the  species,  and  the  amount  of  it,  and  must 
ground  their  opinion  both  on  the  basis  of  the  written  acts  and  their 
own  observations  as  to  the  influence  the  disease  may  have  exercised 
and  yet  exercises  on  the  imagination,  impulses  and  acts  of  the  ac- 
cused, and  whether  and  in  what  degree  the  disturbed  state  of  mind 
has  existed  at  the  period  when  the  crime  was  committed." 

In  France  the  law  recognizes  the  right  of  the  judge  d'instruction 
(or  magistrate)  to  enlighten  himself,  by  obtaining  the  opinion  of  men 
engaged  in  the  practice  of  mental  medicine,  whenever  he  feels  in 
doubt.  The  Code  of  Civil  Procedure,  Part  I.,  Book  II.,  Chap.  XIV., 
enacts  the  mode  of  nominating  experts.  The  salient  points  are  as 
follows,  viz. : 

"  When  the  magistrate  perceives  during  the  examination,  that 
the  person  accused  of  a  crime  does  not  enjoy  the  full  measure 
of  his  intelligence,  he  suspends  his  examination  and  makes  an 
order  by  virtue  of  which  one,  two  or  three  experts  are  requested 
to  examine  the  accused.  He  may  also  have  been  induced  to  take 
this  course  in  consequence  of  the  action  of  the  friends  of  the  pris- 
oner, for  after  the  crime  has  been  committed  his  friends  may  say^ 


EXPERT    TESTIMONY    IN    CRIMINAL   TRIALS.  299 

'  He  was  insane.'  '  Here  is  the  proof.  His  medical  attendant  has 
seen  him  and  attested  in  a  certificate",  which  we  place  before  you,  that 
such  is  the  fact'  The  experts,  who  make  the  examination,  take  an 
oath,  and  the  particulars  of  the  crime  and  the  prisoner's  history  as 
ehcited  by  the  magistrate  are  communicated  to  them,  if  they  desire 
them.  They  then  examine  the  accused,  either  at  his  own  house  if 
he  is  provisionally  at  liberty,  or  at  the  prison  if  he  is  detained  there. 
The  visits  of  the  experts  are  made  freely  and  without  witnesises,  just 
as  often  as  they  see  fit.  The  governor  of  the  prison  conforms  to 
their  wishes  and  causes  the  prisoner  to  be  specially  inspected  by  the 
jail  wardens  if  it  is  desired.  The  experts  have  full  powers  to  insure 
a  thoroughly  satisfactory  examination  in  a  house  or  in  prison.  If 
the  experts  are  not  able  to  make  up  their  minds,  as  may  happen  in 
cases  of  feigned  insanity,  the  prisoner  may  be  placed  provisionally 
in  an  insane  asylum,  that  he  may  be  examined  there  with  still  more 
care  and  under  watchful  supervision.  The  experts  see  him  as  often 
as  they  please,  and  having  arrived  at  a  decision  report  to  the  mag- 
istrate. If  they  report  that  the  prisoner  is  insane,  the  magistrate 
probably  accepts  their  verdict  as  final,  and  issues  an  order  of  '  non 
lieu,'  or  no  jurisdiction.  The  prisoner  is  now  regarded  as  irrespon- 
sible, and  remains  in  an  asylum  until  the  superintendent  sees  fit  to 
discharge  him. 

"The  great  trouble  is,  that  dangerous  lunatics  are  often  discharged 
and  commit  fresh  crimes.  If  the  examination  by  these  experts  has 
been  instituted  by  the  friends  of  the  prisoner,  and  they  report  him 
sane  after  the  family  physician  pronounces  him  insane,  the  magistrate 
then  orders  an  '  expertise^  that  is,  other  experts  are  ordered  to  make 
a  fresh  examination.  If  these  experts,  who  observe  the  prisoner 
under  the  same  condition  as  the  former  board  of  experts,  decide  that 
the  prisoner  is  insane,  the  magistrate  probably  adopts  their  opinion 
and  the  prisoner  goes  to  an  asylum.  But  if  the  second  board  of  ex- 
perts appointed  by  the  magistrate  also  think  the  prisoner  responsible, 
the  prisoner  is  committed  for  trial.  The  president  of  the  court  will 
allow  no  other  physicians  to  testify  on  the  trial,  besides  the  experts 
previously  ordered  to  that  duty  by  the  magistrate.  The  counsel  for 
the  prisoner  only,  may  set  forth  the  views  of  the  family  physician  if 
the  latter  still  maintains  the  prisoner's  insanity.  If  the  president  of 
the  court  is  in  doubt  as  to  the  mental  responsibility  of  the  prisoner, 
notwithstanding  the  opinion  of  the  experts,  he  expresses  it  to  the 
jury,  and  has  the  right  to  adjourn  the  trial  to  the  next  term  in  order 


300  PSYCHOLOGICAL   MEDICINE. 

to  appoint  still  other  experts  to  examine  the  prisoner's  state  of  mind. 
The  prisoner  is  sent  back  to  prison,  and  is  at  the  disposal  of  the  new 
board  of  experts  until  they  have  made  their  report." 

I  think  the  French  practice,  in  general,  most  excellent.  They 
err,  however,  I  think,  in  not  recognizing  reasoning  mania  or  emo- 
tional insanity  as  in  general  an  incurable  state  of  chronic  insanit)^, 
associated  as  it  generally  is  with  congenitally  feeble  moral  powers, 
a  true  moral  imbecility,  and  in  not  remanding  such  cases  when  ad- 
judged insane  to  an  asylum  for  life,  as  when  discharged  they  will 
inevitably  commit  other  crimes,  as  they  have  often  done  in  England, 
France,  and  in  our  own  country. 

What  we  want  is,  to  ascertain  the  mental  condition  of  the  pris- 
oner; to  protect  him  from  punishment  if  he  is  insane,  to  protect 
society  from  the  injury  of  admitting  insanity  as  a  plea,  when  the  act 
is  really  criminal,  and  finally,  to  avoid  discharging  those  who  are 
found  "not  guilty,  on  the  ground  of  insanity,"  until  they  are  perfectly 
restored  to  mental  health. 

The  law  of  insanity  should  be  more  conformable  than  it  is  with 
medical  science,  as  the  present  law  lays  down  such  a  definition  of 
madness  that  nobody  is  hardly  ever  really  mad  enough  to  be  within 
it.  There  are  many  cases  where  the  person  is  clearly  not  responsi- 
ble and  yet  knows  right  from  wrong.  It  is  a  law  diametrically  op- 
posed to  the  pathology  of  insanity,  which  rules  that  it  is  only  when 
mental  disease  produces  incapacity  to  distinguish  between  right  and 
wrong,  that  immunity  from  the  penal  consequences  is  admitted. 
The  law  should  recognize  the  absence  of  the pozver  of  self-control,  and 
should  be  altered  in  the  interests  of  humanity  and  justice,  so  as  to 
introduce  as  an  essential  elemerit  of  responsibility,  the  power  of  self- 
control  tvlien  destroyed  or  suspended  by  mental  disease.  We  know  far 
more  about  insanity  than  they  did  in  the  last  generation,  and  it  is 
obviously  unfair  that  laws  pertaining  to  insanity,  when  the  knowl- 
edge of  that  disease  was  comparatively  in  its  infancy,  should  not  be 
amended  to  keep  pace  with  our  increased  knowledge  of  the  pathology 
of  mental  disease.  There  are  many  persons  born  with  a  predisposi- 
tion to  insanity,  and  symptoms  indicating  that  disease  display  them- 
selves at  frequent  intervals  through  the  whole  course  of  life,  but  for 
many  years  may  never  reach  such  a  pitch  as  to  induce  those  in  con- 
tact with  such  persons  to  treat  them  as  insane.  When  an  overt  act 
is  committed  by  such  persons,  can  anyone  question  the  value  of  a 
careful  examination  of  the  past  life  and  acts  of  the  accused  ?     His 


EXPERT   TESTIMONY    IN    CRIMINAL   TRIALS.  3OI 

life  has  exhibited  the  natural  history  of  insanity,  and,  with  our  present 
accurate  and  trustworthy  methods  of  investigation,  a  careful  and  ex- 
perienced physician  in  nervous  and  mental  diseases  can  clearly  point 
out  to  the  lawyer  and  jurist  the  unmistakable  evidences  of  mental 
disease,  which  the  latter,  necessarily,  alone  and  unaided,  could  not 
discover.  The  physician  and  lawyer  should  mutually  aid  each  other 
in  such  investigations,  impartially  and  by  the  light  of  science.  There 
should  be  no  rule  of  law  that  conflicts  with  the  elementary  truths  of 
insanity,  on  which  only  such  rules  should  be  founded,  and  medical 
jurisprudence  is  of  value  only  so  far  as  it  represents  the  acknowl- 
edged truths  of  science.  For  instance,  in  a  homicide,  even  though 
the  reasoning  powers  be  intact,  and  there  be  a  capacity  to  distinguish 
between  right  and  wrong,  we  may  frequently  find  epilepsy  to  be  the 
very  phase  of  mental  disturbance  which  prompted  the  criminal  act  ; 
and  if  in  any  given  case  I  were  called  upon  by  a  lawyer  who  laid 
before  me  the  evidence  to  be  produced  at  a  trial,  where  the  fact  of 
the  existence  of  epilepsy  could  be  plainly  established,  and  I  should 
be  asked  for  my  opinion  respecting  such  evidence,  I  should  tell  him 
that  he  had  a  good  case  and  that  I  regarded  the  prisoner's  legal  re- 
sponsibility as  presumptively  annulled,  and  that  the  burden  of  proof 
lay  on  the  party  that  alleged  the  contrary;  as  in  none  of  the  neuroses 
is  the  presence  of  the  elements  of  moral  obliquity,  emotions  of  sus- 
picion as  the  mainspring  of  conduct,  maniacal  fury,  sudden  ebulli- 
tions alternating  with  periods  of  lucidity,  suicidal  and  homicidal 
mania,  so  conspicuous  as  in  epilepsy,  where  we  find  every  modifica- 
tion of  blind  and  destructive  impulse. 

There  are  also  forms  of  chronic  insanity,  a  prominent  example  of 
which  has  lately  been  brought  to  my  notice  in  the  case  of  a  young 
man,  in  which  the  mental  manifestations  are  distinguished  less  by 
delusions  and  gross  incoherence  than  by  a  certain  mental  irregularity 
and  unsteadiness,  easily  recognized  by  one  familiar  with  diseases  of 
the  brain,  where  the  mind  is  agitated  and  controlled  by  each  new 
impulse;  and  yet  this  form  of  mental  disease  under  our  present  law 
is  clearly  incompatible  with  the  kind  of  insanity  which  annuls  crimi- 
nal responsibility,  for,  as  a  rule,  all  these  cases  can  clearly  distinguish 
between  right  and  wrong.  The  present  law  should  be  amended  so 
as  to  read  that  "  homicide  is  not  criminal,  if  the  person  by  whom  it 
is  committed  is,  at  the  time  when  he  commits  it,  prevented  by  any 
disease  affecting  his  mind  from  controlling  his  own  conduct." 

Finally,  I  would  speak  of  the  immense  medico-legal  importance 


302  PSYCHOLOGICAL    MEDICINE. 

of  the  recognition  of  the  mental  condition  that  is  the  precursor  of 
decided  insanity.  The  depression,  unwonted  excitability,  disregard 
of  the  minor  proprieties  of  life,  the  change  which  comes  over  the 
warmest  affections,  quick  changes  and  rapid  transitions  in  the  cur- 
rent of  the  feelings,  sleeplessness,  and  a  complete  change  of  the  char- 
acter and  habits,  the  person,  meanwhile,  entertaining  no  delu- 
sions, but  occasionally  losing  his  self-control,  the  general  air  and 
manner  at  such  times  being  strongly  expressive  of  the  inward  emo- 
tions ;  intervals  of  perfect  calmness  and  self-control,  during  which 
the  person  clearly  discerns  his  true  relations  to  others,  and  even, 
perhaps,  recognizes  the  influence  which  the  incipient  disease  exer- 
cises over  his  feelings  and  actions,  with,  finally,  the  utter  downfall  of 
the  integrity  of  the  intellect,  manifested  by  the  fury  of  mania  or  the 
moodiness,  suspicion,  depression,  and  impulses  toward  self-destruc- 
tion of  melancholia.  All  these  are  the  successive  links  forged  in  the 
chain  of  insanity,  the  study  of  which  is  full  of  interest  to  the  student 
of  mental  pathology,  who  is  interested  in  the  amelioration  of  this 
scourge  of  life,  and  to  those  who  are  interested  in  leading  back  the 
wandering  mind  out  of  the  darkness  and  mazes  of  disease  into  the 
unclouded  light  of  reason. 


CHAPTER  XVII. 

CODIFICATION    OF    THE    COMMON    LAW    AS    TO    INSANITY. 

I  AM  sure  that  the  acute  minds  of  many  of  our  most  distinguished 
physicians  and  lawyers  have  not  failed  to  perceive  the  incongruities 
and  deficiencies  of  the  present  law,  and  yet  there  are  many  who  seem 
adverse  to  any  attempt  to  make  the  law  of  insanity  more  conform- 
able than  it  is  with  medical  science.  Lord  Justice  Bramwell  told 
the  select  committee  on  the  homicide  bill :  "  I  think  that  although 
the  present  law  lays  down  such  a  definition  of  madness  that  nobody 
is  hardly  ever  really  mad  enough  to  be  within  it,  yet  it  is  a  logical 
and  good  definition."  He  further  stated  that,  in  his  opinion,  "  the 
law  was  right,  because  it  might  deter  many  insane  persons  from 
crime  by  the  threat  of  punishment."  Lord  Justice  Blackburn,  in  his 
testimony  before  the  select  committee  on  the  homicide  bill,  said : 


CODIFICATION    OF   THE    COMMON    LAW    AS   TO    INSANITY,  303 

"  On  the  question  of  what  amounts  to  insanity  that  would  prevent  a 
person  being  punishable  or  not,  I  have  read  every  definition  which  I 
could  meet  with,  and  never  was  satisfied  with  one  of  them,  and  have 
endeavored  in  vain  to  make  one  satisfactory  to  myself.  I  verily  be- 
lieve that  it  is  not  in  human  power  to  do  it.  You  must  take  it  that 
in  every  individual  case  you  must  look  at  the  circumstances  and  do  the 
best  you  can  to  say  whether  it  was  the  disease  of  the  mind  which 
was  the  cause  of  the  crime,  or  the  party's  criminal  will."  He  also 
said  :  "  But  we  cannot  fail  to  see  that  there  are  cases  where  the  person  is 
clearly  not  responsible,  and  yet  knew  right  from  wrong^ 

He  then  goes  on  to  give  the  case  of  a  woman  he  tried  who  had 
killed  one  child  and  was  going  to  kill  another,  but  who  fortunately 
dropped  the  second  child  and  went  to  a  neighbor,  telling  her  what 
she  had  done.  This  woman  clearly  knew  the  difference  between 
right  and  wrong,  and  knew  the  character  of  the  act,  and,  on  the 
definition  in  the  McNaughton  case,  in  1843,  was  guilty.  Lord  Jus- 
tice Blackburn,  however,  as  the  woman  was  a  raving  maniac,  so 
charged  the  jury  on  the  ground  of  exceptional  cases,  that  the  jury 
found  her  "  not  guilty,  on  the  ground  of  insanity,"  and  rightly. 

The  Lord  Chief  Justice  of  England,  in  his  criticism  of  Sir  Fitzjames 
Stephens's  plan  of  codifying  the  law  of  insanity,  said  : 

As  the  law,  as  expounded  by  the  judges  in  the  House  of  Lords,  now  stands,  it  is  only 
when  mental  disease  produces  incapacity  to  distinguish  between  right  and  wrong  that  im- 
munity from  the  penal  consequences  of  crime  is  admitted.  The  present  bill  introduces  a 
new  element,  the  absence  of  the  power  of  self-control.  I  concur  most  heartily  in  the 
proposed  alterations  of  the  law,  having  been  always  strongly  of  opinion  that,  as  the 
pathology  of  insanity  abundantly  establishes,  there  are  forms  of  tnental  disease  in  which, 
though  the  patient  is  quite  aware  he  is  about  to  do  wrong,  the  will  becomes  overpowered 
by  the  force  of  irresistible  impulse  ;  the  power  of  self-control,  when  destroyed  or  suspended 
by  mental  disease,  becomes,  I  think,  ajt  essential  element  of  responsibility. 

The  Lord  Chief  Justice  of  England,  in  his  weighty  and  truly  sci- 
entific opinion,  the  intrinsic  weight  of  which  is  immense,  deserves 
the  admiration  of  both  the  medical  and  legal  profession  all  over  the 
world.  Lord  Moncrief,  the  Lord  Justice  Clerk  of  Scotland,  has  said 
from  the  bench  that,  "  in  point  of  fact,  there  are  very  few  lunatics  who  do 
not  know  right  from  zvrong,''  an  opinion  which  I  have  myself  insisted 
on  before  the  New  York  Medico-legal  Society,  in  two  different  papers 
read  there.  If  we  have  the  absence  of  self-control  produced  by  disease 
of  the  body  affecting  the  mind,  in  any  given  case  of  homicide  on  trial, 
it  seems  to  me  that  every  physician  and  every  fair-minded  lawyer 
will  concur  in  acknowledging  that  we  have  here  a  philosophic  or 


304  PSYCHOLOGICAL   MEDICINE. 

scientific  principle  on  which  to  found  the  plea  of  "  not  guilty,  on  the 
ground  of  insanity,"  and  one  which  includes  the  cases  of  all  insane 
criminals.  It  does  not  seem  to  me  that,  in  the  question  of  what  con- 
stitutes insanity,  the  members  of  the  two  great  professions  of  law  and 
medicine  should,  or  at  all  need  to,  entertain  essentially  different  and 
irreconcilable  views,  or  that  on  the  question  of  the  irresponsibility 
of  criminals  who  are  supposed  to  be  insane,  there  should  be  such  a 
diversity  of  opinion  as  exists  to-day.  The  physician  naturally  stu^ 
dies  the  whole  history  of  his  patient  and  his  ancestry,  and  searches 
for  the  causes  of  any  bodily  and  mental  changes  that  he  finds,  and 
thus  arrives  at  the  true  pathology  of  the  disease,  while  the  lawyer 
and  jurist  are  mainly  interested  in  the  existence  of  mental  disease,  its 
degree,  and  its  infiiience  on  conduct.  We  know  far  more  about  in- 
sanity than  they  did  in  the  last  generation,  and  it  is  obviously  unfair 
that  laws  pertaining  to  insanity  when  the  knowledge  of  that  disease 
was  comparatively  in  its  infancy  should  not  be  amended  to  keep 
pace  with  our  increased  knowledge  of  the  pathology  of  mental  dis- 
ease. In  that  form  of  homicidal  monomania  where  the  patient  is 
possessed  of  a  sudden,  blind,  motiveless,  unreasoning  impulse  to  kill, 
I  do  not  think  that  there  is  any  desire,  motive,  or  reasoning  intention 
to  commit  such  a  deed,  the  true  pathology  of  this  form  of  insanity 
consisting,  it  seems  to  me,  in  a  vis  a  tevgo  received  from  the  diseased 
action  of  the  brain.  We  have  here  a  diseased  state  of  mi^id  with  ab- 
sence of  self-control.  We  have  in  suicidal  monomania  also  a  vis  a 
tergo  received  from  the  diseased  action  of  the  brain,  in  which,  while 
our  patient  perhaps  exhibits  no  other  mental  derangement,  with  no 
delusion  or  other  intellectual  disorder,  has  the  blind,  motiveless,  un- 
reasoning impulse  to  suicide,  which,  alike  with  the  ho-micidal  im- 
pulse, is  the  joint  result  of  undoubted  insanity.  In  both  these  cases 
the  impulse  is  long,  enduring,  and  gives  rise  to  actions  of  patient 
deliberation  and  of  cunning  contrivance.  The  physician  and  the 
legal  profession  are  willing  alike  to  recognize  disease  in  the  suicidal 
act ;  why,  then,  the  apparent  unwillingness  to  recognize  disease  in 
the  homicidal  act?  We  must  not  look  at  these  questions  socially  or 
ethically,  but  by  the  aid  of  the  light  of  modern  pathology,  as  the 
Lord  Chief  Justice  of  England  has  done  already.  No  honest,  scientific 
conclusion,  however  great  an  advance  it  may  be  upon  existing  views, 
is  a  dangerous  innovation.  There  is  a  very  false  idea  in  the  minds 
of  well-educated  persons,  which  I  desire  here  to  correct,  that  the 
skilled  opinions  of  the  medical  witness, — the  result  of  years  of  reflec- 


CODIFICATION    OF   THE    COMMON    LAW   AS    TO    INSANITY.  305 

tion  and  experience  in  his  particular  specialty, — that  the  perceptions 
of  truth  of  the  medical  expert  are  obscured  by  the  fact  of  his  receiv- 
ing a  fair  compensation  for  his  services.  The  medical  expert  is  called 
upon  by  the  lawyer,  who  lays  before  him  the  evidence  to  be  produced, 
and  asks  him  for  his  opinion  respecting  it.  The  physician  informs 
him  either  that,  if  he  can  prove  the  facts  as  he  states  them,  he  has  a 
good  case,  and  expresses  his  willingness  to  testify  to  that  effect,  or 
he  tells  him  that  the  facts  of  the  case  do  not  justify  the  construction 
which  the  lawyer  desires  to  put  upon  them,  and  declines  to  testify  in 
the  case. 

The  testimony  of  an  honest  medical  expert  is  never  wholly  and 
unconditionally  in  favor  of  one  side  only,  unless  such  a  result  be  war- 
ranted by  the  facts.  His  judgment  is  wi^if  warped  by  the  fact  of  his 
receiving  compensation.  If  a  lawyer  comes  to  the  physician  and, 
by  an  exaggerated  statement  of  facts,  enlists  the  physician's  aid  as  a 
medical  witness,  he  will  find  that,  if  upon  an  examination  of  the  case 
the  facts  do  not  appear  as  represented  to  the  physician,  the  latter,  if 
a  scientific  man,  will  either  modify  or  entirely  abandon  his  first  con- 
clusion, and  decline  to  testify  in  the  suit. 

The  frequency  of  epilepsy,  and  its  injurious  effect  on  the  mind, 
makes  its  medico-legal  relations  a  subject  of  great  importance,  and  I 
have  elsewhere  pointed  out  that  epileptics  are  to  be  classed  in  the 
most  homicidal  group  of  all  the  insane. 

The  late  Dr.  Ray,  of  Philadelphia  (one  of  the  most  eminent  of  Amer- 
ican experts,  and  one  of  the  most  brilliant  and  scientific  men  of  the 
profession,  a  man  who  had  devoted  himself  to  the  study  of  mental 
pathology  for  years,  and  who  in  his  writings  always  displayed 
thorough  observation  and  original  thought,  and  to  whom,  in  his 
contributions  to  mental  pathology,  his  friends  can  fitly  apply  the 
words  of  Sartor  Resartus :  "  Beautiful  it  is  to  understand  and  know 
that  a  thoiigJit  did  never  yet  die,  that  as  thou,  the  originator  thereof, 
hast  gathered  it  and  created  it  from  the  whole  past,  so  thou  wilt 
transmit  it  to  the  v^holQ  future  "),  speaks  as  follows  respecting  epi- 
lepsy : 

The  excessive  susceptibility  of  epileptics  to  nervous  impressions,  which  become  dis- 
torted if  not  utterly  changed  on  their  vi^ay  to  the  sensorium,  is  a  phenomenon  not  clearly 
recognized  by  the  profession  at  large,  although  it  cannot  have  failed  to  meet  the  atten- 
tion of  the  closer  observer.  In  medico-legal  inquiries,  it  should  never  be  ignored  or  for- 
gotten, for  it  may  be  the  very  phase  of  mental  disturbance  which  prompted  the  criminal 
act.  In  view  of  what  we  already  know  of  epilepsy,  and  of  what  still  remains  to  be  learned, 
we  have  a  right  to  require  the  utmost  circumspection  and  closest  investigation  whenever 

20 


306  PSYCHOLOGICAL    MEDICINE. 

the  legal  liabilites  of  epileptics  are  in  question.  The  fact  of  its  existence  being  estab- 
lished, is  it  going  too  far  to  say  that  legal-  responsibility  is  presumptively  annulled,  and 
that  the  burden  of  proof  lies  on  the  party  that  alleges  the  contrary  ?  People  are  scarcely 
ready  for  it  vet,  perhaps,  but  to  that  complexion  must  they  come  at  last. 

Esquirol  says  that  out  of  339  female  epileptics  treated  in  Charen- 
ton,  only  sixty  exhibited  no  aberration  of  intelligence.  An  epileptic 
convulsion  may  not  occur,  but  may  be  represented  by  sadness,  dejec- 
tion, by  sullenness,  by  ebullitions  of  rage  and  ferocity, — ■d.niania  tran- 
sitoria,  signalized  by  suicide,  homicide,  and  ever}'  modification  of 
blind  and  destructive  impulse.  Trousseau,  the  great  French  physician, 
has  said  that,  wherever  there  was  a  revolting  or  motiveless  crime, 
he  suspected  the  existence  of  epilepsy ;  and  the  late  case  of  Laros,  of 
Pennsylvania,  who  poisoned  his  whole  family,  is  an  example  of  just 
such  cases.  The  awakening  from  epileptic  stupor  may  often  resolve 
itself  into  an  outburst  of  mental  derangement,  manifested  by  extreme 
vehemence,  violence  and  destructiveness. 

I  have  also  stated  that  puerperal  women  and  women  at  the  cli- 
macteric period  are  subject  at  times  to  dangerous  delusions,  and  also 
that  kleptomania  is  a  peculiarity  of  a  certain  number  of  cases  of  gen- 
eral paralysis.  These  facts  are  classical,  and  should  be  so  accepted 
by  the  legal  profession.  One  of  the  last  cases  of  general  paralysis 
under  my  care,  was  that  of  a  gentleman  of  prominence  and  wealth, 
who  would  slyly  secrete  articles  of  absolutely  no  value  to  himself, 
and  carry  them  home,  and  who,  after  being  placed  under  my  care, 
manifested  this  peculiarity  for  many  months,  so  that  his  nurse  would 
every  few  days  have  quite  a  collection  of  small  articles  to  gather  up 
and  return  to  their  appropriate  places.  I  have  observed  this  in  cases 
of  the  ordinar}^  type  with  grand  delirium,  and  also  in  the  senile  form, 
characterized  by  progressive  enfeeblement  of  the  intellect  and  of 
long  duration.  It  is  a  very  interesting  question  in  mental  pathology, 
whether  we  are  entitled  to  hold,  in  general  paralysis  of  the  insane, 
that  the  resumption  of  apparently  healthy  mental  action,  which  we 
see  in  the  remissions  that  sometimes  occur,  is  compatible  and  co- 
existent with  persistent  structural  degeneration  ?  In  other  forms  of 
mental  disease  also,  after  a  mental  darkness  created  and  maintained 
for  years  by  the  presence  of  brain  wasting,  hypertrophy  or  con- 
solidation of  brain-tissue,  with  what  cerebral  condition  can  we  iden- 
tify these  sudden  flashes  of  restored  intellectual  light?  In  a  paper 
on  "  Mental  Responsibility  and  the  Diagnosis  of  Insanity  in  Crim- 
inal Cases,"  read  before  the  New  York  Medico-Legal  Society,  and 


CODIFICATION    OF   THE    COMMON    LAW   AS    TO    INSANITY.  307 

subsequently  published  in  the  l^ondon  Journal  of  Psychological  Med- 
icine and  Mental  Pathology,  I  suggested  a  series  of  eight  questions, 
which,  it  seems  to  me,  if  adopted  by  jurists  in  criminal  cases,  would 
form  a  most  efficient  and  just  test  in  any  given  case.  Perhaps  the  legal 
profession  may  prefer  the  simpler  proposition,  which,  as  the  result 
of  Sir  Fitzjames  Stephens's  attempt  to  codify  the  common  law  of 
England  on  insanity,  may  be  briefly  summed  up  as  follows,  viz.  : 
Homicide  is  not  criminal,  if  the  person  by  whom  it  is  committed  is,  at  the 
time  when  he  commits  it,  prevented  by  any  disease  affecting  his  mind 
from  controlling  his  own  conduct.  This  is  very  simple  and  very  com- 
prehensive, and  therefore  the  legal  profession  may  very  properly  pre- 
fer it  to  my  own.  The  eight  questions  which  I  proposed  in  my 
paper  are  as  follows,  viz.  : 

1st.  Have  the  prisoner's  volitions,  impulses  or  acts  been  determined  or  influenced  at 
all  by  insanity,  and  are  his  mental  functions — thought,  feeling,  and  action— so  deranged, 
either  together  or  separately,  as  to  incapacitate  him  for  the  relations  of  life  ? 

2d.  Does  the  prisoner  come  of  a  stock  whose  nervous  constitution  has  been  vitiated  by 
some  defect  or  ailment  calculated  to  impair  its  efficiency  or  derange  its  operations  ? 

3d.  Has  the  prisoner  been  noticed  to  display  mental  infirmities  or  peculiarities  vs'hich 
are  due  either  to  hereditary  transmission  or  present  mental  derangement  ? 

4th.  Has  the  prisoner  the  ability  to  control  mental  action,  or  has  he  not  sufficient  men- 
tal power  to  control  the  sudden  impulses  of  his  disordered  mind,  and  does  he  act  under 
the  blind  influence  of  evil  impulses,  which  he  can  neither  regulate  nor  control  ? 

5th.  Has  the  act  been  influenced  at  all  by  hereditary  taint,  which  has  become  intensi- 
fied, so  that  the  morbid  element  has  become  quickened  into  overpowering  activity,  and  so 
that  the  moral  senses  have  been  overborne  by  the  superior  force  derived  from  disease  ? 

6th.  Was  the  act  effected  by,  or  the  product  of,  insane  delusions  ? 

7th.  Was  the  act  performed  without  adequate  incentive  or  motive  ? 

8th.  Does  the  prisoner  manifest  excitement  or  depression  ;  moody,  difficult  temper;  ex- 
traordinary proneness  to  jealousy  and  suspicion;  a  habit  of  unreasonably  disregarding 
ordinary  ways,  customs,  and  observances ;  an  habitual  extravagance  of  thought  and  feel- 
ing; an  inability  to  appreciate  nice  moral  distinctions;  and,  finally,  does  he  give  way  to 
gusts  of  passion  and  reckless  indulgence  of  appetite  ? 

Some,  or  all,  of  these  are  found  generally  in  connection  with  trans- 
mitted mental  infirmity.  It  may  be  argued  that  these  mental  defects 
signify  not  mental  unsoundness,  but  human  imperfection.  Certainly, 
if  we  take  the  manifestations  in  No.  8, — any  one  of  them,  singly  and 
alone, — we  cannot  claim  such  a  one  as  invariably  an  indication  of 
insanity;  but,  on  the  other  hand,  under  certain  circumstances,  each 
one  of  them  may  be  an  unmistakable  sign  of  insanity,  or  rather  of  a 
morbid  cerebral  state  which  may  readily  lapse  into  insanity.  The 
disappointments  and  calamities  of  life  obviously  act  with  greater 
effect  upon  an  unstable  mental  organism ;  these  causes  of  disturb- 


308  PSYCHOLOGICAL    MEDICINE. 

ance  meeting  with  a  powerful  co-operating  cause  in  the  constitu- 
tional predisposition.     Sometimes  a  crime,  even  when  there  have  been 
no  previous  symptoms  to  indicate  disease,  marks  the  period  when  an 
insane  tendency  has  passed  into  actual  insanity, — when  a  weak  organ 
has  given  way  under  the  strain  put  upon  it.     It  is  an  important  point 
in  mental  pathology  to  recognize  the  fact,  rendered  classical  by  an- 
tiquity,— Celsus.who  practiced  during  the  reign  of  Tiberius,  and  who 
wrote  eight  books  on  medicine,  having  clearly  expressed  this  law  of 
morbid  sympathies  and  idiosyncrasies, — that  it  is  the  diseased  or 
weak  organ  that  retains  all  too  strong  impressions  that  affect  the 
economy,  and  which  becomes  the  centre  with  which  are  connected 
all  the  sensations  and  all  the  disorders  communicated  to  the  body. 
The  laws  of  hereditary  transmission  operate  very  often  in  the  devel- 
opment, in  successive  generations  of  the  same  family,  of  an  unstable 
mental  organism,  too  delicate  to  stand  the  wear  and  tear  and  haste  of 
modern  civilization,  and  such  persons  also  often  exhibit  a  true  con- 
genital deprivation  of  the  normal  intellectual  faculties.     There  is  a 
class  of  persons,  with  a  peculiar  nervous  temperament,  who  inhabit 
the  border  land  between  crime  and  insanity,  one  portion  of  which 
exhibit  some  insanity,  but  more  of  vice;  and  the  other  portion  of 
which  exhibit  some  vice,  but  a  preponderance  of  insanity,  and  it  is 
very  difficult  to  form  a  just  estimate  of  the  moral  responsibility  of 
such  persons,  especially  when  we  reflect  upon  the  fact  that  moral 
feeling  is  a  function  of  organization,  and  is  as  essentially  dependent 
upon  the  integrity  of  that  part  of  the  nervous  system  which  ministers 
to  its  manifestations,  as  in  any  other  display  of  mental  function.     I 
have  met  with  cases  in  which,  as  a  result  of  parental  insanity,  there 
has  been  a  seemingly  complete  absence  of  moral  sense  and  feeling 
in  the  offspring,  and  this  has  been  a  true  congenital  deprivation,  or  a 
moral  imbecility,  so  to  speak ;  of  course,  such  children  can  hardly  fail 
to  become  criminals.     In  this  connection,  it  is  interesting  to  note 
that  moral  degeneration  often  follows  as  a  sequence  upon  disease  or 
injury  to  the  brain.     A  severe  attack  of  insanity  sometimes  produces 
the  same  effect,  the  intellectual  faculties  remaining  as  acute  as  ever, 
while  the  moral  sense  becomes  obliterated.     It  is  an  important  med- 
ico-legal point  relating  to  psychological  medicine,  that  not  every 
improvement  is  the  commencement  of  convalescence,  nor  is  the  ap- 
pearance of  a  few  healthy  traits  an  unquestionable  presage  of  recovery. 
It  is  not  rare  to  find  a  complete  remission,  consisting  in  the  tem- 
porary disappearance  of  every  sign  of  mental  disease  during  the  first 


CODIFICATION    OF   THE    COMMON    LAW   AS    TO    INSANITY.  3O9 

month  of  an  attack  of  insanity,  followed  by  a  renewed  intensity  of  the 
disease. 

This,  of  course,  is  no  more  a  recovery  from  disease  of  the  brain 
than  the  remission  in  malarial  fever  is  indicative  of  recovery  from 
malarial  fever.  I  have  repeatedly  witnessed  such  remissions,  even 
in  incurable  organic  diseases  of  the  brain.  We  cannot  explain  these 
cases,  but  that  they  occur  is  perfectly  well  known  to  every  specialist 
in  diseases  of  the  nervous  system,  as  well  as  to  most  observant  phy- 
sicians. It  should  be  borne  in  mind,  therefore,  that  there  may  be  a 
condition  of  mind  resembling  recovery,  but  where  there  is  a  latent 
irritability  of  the  brain  ready  to  break  out  in  active  insanity  were  not 
such  persons  prevented  from  assuming  the  cares,  anxieties,  and 
responsibilities  of  life  for  themselves.  Unreasonable  and  uncontrol- 
lable restlessness  and  excitement  or  depression  generally  character- 
izes these  apparent  recoveries,  and  also  very  often  a  peculiar  bitter- 
ness towards  the  institution  where  they  have  been  treated  with  all 
gentleness  and  skill ;  whereas,  in  genuine  recoveries,  it  is  the  rule  to 
find  patients  entertaining  the  most  lively  gratitude  to  their  physician 
and  toward  the  institution  in  which  they  were  treated.  Dr.  Pliny 
Earle,  of  Northampton,  Massachusetts,  one  of  the  most  eminent 
American  alienists,  the  late  Dr.  Ray,  of  Philadelphia,  and  the  most 
eminent  English  alienists  have  all  expressed  themselves  unanimously 
on  this  point. 


PART  11. 

INTRODUCTORY  CHAPTER. 

MODERN    NERVOUS    DISEASE. 

Observant  physicians  know  that  neurotic  affections  are  increasing 
and  multiplying.  We  have  to-day,  as  Americans,  a  morbid  ner- 
vousness which  I  consider  to  be  an  entirely  new  state  of  the  system, 
developing  itself  in  modern  society  and  making  itself  manifest  by 
neuralgia,  sick  headache,  dyspepsia,  hay-fever,  and  neurasthenia  or 
nervous  exhaustion.  This  unprecedented  nervousness,  when  it  does 
not  pass  into  actual  disease,  is  also  indicated  by  an  increased  sensi- 
tiveness to  heat  and  -cold,  and  a  greatly  augmented  susceptibility  to 
the  action  of  stimulants  and  narcotics.  Fat  persons  are  less  numer- 
ous and  thin  persons  more  numerous  in  the  well-fed  classes  of  society 
than  was  formerly  the  case.  The  increasing  nervousness  of  this 
country  is  most  clearly  evinced  by  the  connection  with  and  influence 
of  the  nervous  system  on  other  diseases  not  properly  nervous.  Thus, 
in  diabetes,  the  nervous  system  is  in  intimate  relation  with  the  dis- 
ease ;  and  I  consider  that  it  is  often  induced  by  mental  anxiety  and 
distress,  or  by  sudden  fear  and  shock.  It  seems  to  me  to  be  advanc- 
ing,/^n/^jr^'z/,  with  the  increase  of  nervous  diseases.  It  is  a  disease 
decidedly  more  common  than  it  used  to  be,  and  I  attribute  its  greater 
prevalence  to  our  present  state  of  civilization.  Bright's  disease  of 
the  kidneys,  nephritis  and  granular  kidney,  are  also  caused  and  ag- 
gravated by  mental  worry  and  anxiety.  Heart  diseases  are  also 
increasing  steadily,  particularly  those  of  neurotic  origin  and  nature. 
Rheumatism  and  gout,  in  both  of  which  there  is  a  nervous  element, 
are  more  severe  than  they  were  years  ago.  Life,  even  though  it  be 
not  shortened,  is  often  made  miserable  by  so-called  mild  nervous  dis- 
orders, such  as  hysteria,  herpes  zoster,  writer's  cramp,  and  sick  head- 
ache. 

Premature  baldness  and  early  decay  of  the  teeth  are  both  far 
more  frequent  than  they  used  to  be,  while  our  leading  druggists  can 


312  PSYCHOLOGICAL    MEDICINE. 

bear  witness  to  the  truth  of  my  statements  by  testifying  as  to  the 
greatly  increased  consumption  of  neurotic  remedies,  such  as  mor- 
phia, hyoscyamus,  conium,  chloral,  the  bromides,  arsenic,  strychnia, 
and  gelseminum.  The  consumption  of  tea,  coffee,  and  tobacco  is 
largely  on  the  increase ;  the  two  former  neurotic  beverages  and  the 
latter  a  great  nerve  sedative.  The  neurotic  circle  in  society  as  well 
as  the  distinctly  insane  circle  of  society,  is  increasing  out  of  propor- 
tion to  the  increase  of  population.* 

The  causes  of  all  this  nervousness  are  due,  first,  to  the  increasing 
complexity  of  the  nervous  system  ;  and  secondly,  to  the  increased 
complexity  of  life.  The  brain,  I  consider,  is  increasing  in  size  in  the 
American  people,  and  this  affects  its  functional  activity  immensely. 
Even  though  its  size  may  not  be  increased,  there  is  a  great  elabora- 
tion in  structure  and  in  the  way  of  a  finer  architecture  of  our  brains, 
new  phases  of  intelligence,  and  new  proclivities  to  nervous  disease. 
Our  brains  are  finer  in  structure  and  more  subtle  in  mechanism,  but 
instability  is  the  result.  The  conditions  of  modern  life  which  act  on 
our  complex  and  excitable  nervous  systems  cause  our  increased  ner- 
vous disease  and  even  mental  disease  itself.  Modern  systems  of 
education  are  also  influential  in  promoting  nervousness  and  in  con- 
tributing to  the  increase  of  mental  and  nervous  diseases.  The  gen- 
eral tendency  of  modern  education  on  the  young  is  to  increase  the 
activity  and  susceptibility  of  the  nervous  system  by  modifying  the 
nutrition  of  the  brain  centres  and  stimulating  their  growth,  and  in 
fragile,  sickly  or  badly  nourished  children,  inducing  brain  exhaustion 
and  organic  disease.  There  is  a  great  increase  in  habitual  headaches, 
which  I  attribute  to  the  exhausting  effects  of  excessive  and  ill-di- 
rected brainwork  in  our  modern  schools.  There  are  serious  dangers 
lurking  in  our  present  teaching  processes.  I  have  traced  sleepless- 
ness, night  terrors,  somnambulism,  epilepsy,  hydrocephalus,  halluci- 
nations and  other  troubles  to  educational  pressure  unwisely  applied 
to  delicate  children. 

The  great  trouble  is  to  make  persons  understand  that  brain  tissue 
degenerations  and  mental  diseases  may  be  separated  by  long  inter- 
vals of  time  from  the  too  premature  and  intense  stimulation  of  the 
brain  which  cause  these  nervous  diseases.  Hydrocephalus,  however, 
is  a  nervous  disease  which  shows  itself  at  once  from  overstimulation 

*  The  whole  subject  of  modern  nervous  diseases  was  first  systematically  studied  by 
Dr.  J.  Crichton  Browne  of  England,  to  whom  the  profession  are  indebted  as  being  the 
pioneer  in  this  interesting  field  of  research,  and  we  have  drawn  largely  on  his  writings. 


MODERN    NERVOUS    DISEASE.  3I3 

of  the  brain  in  the  young,  and  of  late  years  the  increase  in  deaths 
from  this  disease  has  not  been  among  infants,  but  among  children 
and  young  people  from  five  to  twenty  years  of  age,  in  the  educa- 
tional period  of  life.  This  is  a  very  significant  fact.  More  remotely, 
as  a  cause  of  overstimulating  the  brain  by  education,  we  meet  with 
the  preponderance  of  nervous  diseases  in  the  refined  and  educated 
classes.  If  by  premature  and  stimulating  processes  of  education  we 
force  an  elaboration  of  cerebral  structure,  hastening  the  functional 
activity  of  the  brain,  with  no  due  regard  to  the  law  of  evolutional 
precedence — which  nature  observes  in  her  elaboration  of  the  brain  in 
infancy,  childhood  and  adult  age  respectively — we  upset  the  whole 
equilibrium  of  the  brain,  and  serious  nervous  disease  will  necessarily 
follow.  Growth  must  precede  function,  and  if,  while  the  child  is  so 
young  or  delicate  that  functional  activity  is  still  feeble,  we  apply 
undue  exercise  or  stimulation,  the  brain  will  never  be  brought  to  the 
highest  development  of  which  it  is  capable.  The  cerebral  centres, 
if  never  properly  exercised,  never  develop  correctly  ;  but  if  we  over- 
exercise  or  overstrain  the  brain  centres  at  their  nascent  period,  we 
dwarf  and  weaken  them,  disturbing  the  balance  of  mind  by  seriously 
interfering  with  the  natural  sequence  of  the  evolution  of  the  brain 
centres.  The  functional  activity  of  the  brain  is  established  at  differ- 
ent epochs  and  perfected  at  different  rates.  By  cautious  stimulation 
of  the  brain  we  bring  it  to  its  highest  development.  By  undue  haste 
we  ruin  its  functional  activity  forever,  and  can  never  have  a  sound 
and  vigorous  brain.  The  whole  future  complexion  of  mental  life  is, 
in  a  great  part,  determined  by  the  impressions  made  on  the  sensory 
centres  of  the  brain  when  they  are  undergoing  development.  We 
must  aim  in  our  system  of  education  at  a  harmonious  development 
of  body,  brain  and  mind  alike,  and  we  shall  then  attain  progress, 
with  health  combined.  We  must  resist  the  inroads  of  nervous  and 
mental  disease  by  a  due  attention  to  the  regulation  of  the  emotional 
elements,  by  disciplining  the  natural  forces  of  character,  and  by 
placing  before  ourselves  high  ideals.  We  must  remember  to  work 
wisely,  without  haste  as  well  as  with  proper  rest,  in  our  different  vo- 
cations of  life.  Sleep  is  essential  to  mental  health,  as  during  sleep  our 
brain-cells  derive  their  nutritive  renovation  almost  entirely,  and  brain- 
workers  need  much  sleep.  Meals,  to  be  digested,  must  be  eaten 
slowly,  not  hastily,  for  we  are  rapidly  becoming  a  nation  of  dyspep- 
tics from  too  rapid  eating,  and  vertigo  and  giddiness  are  often  due  to 
temporary  derangement  of  the  digestive  organs.     We  may  enjoy 


314  PSYCHOLOGICAL    MEDICINE, 

constitutional  vigor  and  a  well-balanced  development  of  parts,  or  by 
carelessness  and  neglect  we  may  suffer  from  a  constitutional  debility 
and  an  irregular  development  of  parts. 

To  avoid  the  numerous  modern  nervous  diseases,  I  would  finally 
caution  the  educated  and  reading  and  thinking  portion  of  society  to 
be  careful  not  to  violate  those  laws,  the  observance  of  which  is  in- 
dispensable to  the  well-being  of  the  brain.  The  two  states  of  wake- 
fulness and  restlessness  which  often  occur  in  men  of  overworked 
brains  are  to  be  promptly  met  by  leaving  one's  business  and  getting 
away  with  complete  change  of  scene  for  a  month  or  more.  The  diet 
should  be  carefully  regulated  at  the  same  time.  An  overworked 
business  or  professional  man  will  in  a  month  return  home  well  and 
able  to  go  on  with  his  regular  daily  round  of  duty,  when  by  neglect 
of  this  simple  precaution  the  overtasked  brain  gives  way  and  mental 
disease  ensues. 

^Mental  anxiety,  by  producing  sleeplessness  and  unrefreshing  sleep, 
quickly  disturbs  the  normal  balance  of  the  nervous  system  and  de- 
ranges its  functions.  Appetite  is  lost,  digestion  is  impaired,  and  the 
patient  complains  of  pain,  fulness  and  flatulence  after  eating.  The 
pain  may  be  of  a  severe  neuralgic  t}'pe,  causing  gastrodynia.  The 
patient  becomes  emaciated  and  feeble.  Mental  anxiety  also  predis- 
poses the  patient  to  attacks  of  disease  in  various  organs,  both  ab- 
dominal and  thoracic,  of  a  functional  nature.  The  urine  becomes 
acid  and  deposits  a  sediment  of  the  lithates  as  it  cools.  The  kidneys 
and  bladder  are  irritated  by  this  acid  urine  and  pain  and  frequent 
desire  to  pass  water  is  the  result.  There  is  generally  in  cases  of  ner- 
vous exhaustion  from  mental  anxiety,  constipation,  diarrhoea  and 
anaemia.  We  may  also  have  epileptiform  convulsions  complicating 
the  case.  Our  patient  is  now  excessively  nervous  and  liable  to 
sudden  shock  or  terror  from  comparatively  slight  exciting  causes, 
and  such  a  shock  is  a  very  frequent  cause  of  the  epilepsy  I  have 
spoken  of.  These  sudden  and  violent  mental  emotions  are  very 
troublesome  symptoms  to  contend  with,  but  they  disappear  as  we 
build  up  the  nervous  system  of  our  patient.  The  epilepsy  arising 
from  mental  shock  commences  quickly  after  the  occurrence  of  the 
shock,  as  might  be  expected ;  while  the  cases  of  epilepsy  that  are  the 
result  of  continued  mental  anxiety  are  preceded  by  terrible  dreams, 
visions,  startings  or  screaming  out  in  the  night.  I  think  it  possible 
that  a  good  many  cases  of  incurable  epilepsy  are  caused  by  mental 
influences,  and  in   our  treatment  we   must  carefully  guard  against 


MODERN   NERVOUS    DISEASE.  315 

every  influence  which  can  endanger  a  return  or  a  continuance  of  the 
disease.  The  state  of  mental  health  of  an  infant  depends  very  much 
upon  the  mental  state  of  the  mother  while  she  is  nursing,  and  too 
great  care  cannot  be  paid  by  the  family  practitioner  to  this  point. 

Respecting  syphilitic  nervous  disease,  which  is  increasing.  Dr.  J. 
Dreschfeld,  Lecturer  on  Pathology,  Owen's  College,  Assistant  Phy- 
sician, Manchester  Royal  Infirmary,  says : 

Amongst  the  affections  of  the  nervous  system,  those  due  to  syphilitic  lesions  are  cer- 
tainly the  most  interesting,  as  well  from  a  clinical  as  from  a  therapeutic  point  of  view ; 
for  while  on  the  one  hand  the  lesions  occurring  in  the  different  parts  of  the  nervous  sys- 
tem give  rise  to  the  most  varied  symptoms,  an  anti-syphilitic  treatment,  on  the  other 
hand,  is  in  most  cases,  especially  where  the  specific  lesion  has  not  in  its  turn  caused 
irreparable  secondary  degenerations  in  the  nervous  substance,  followed  by  the  happiest 
results.  Though  the  more  exact  study  of  these  diseases  dates  not  many  years  back,  the 
number  of  well-observed  cases  on  record  has  already  reached  several  hundreds  ;  a  pe- 
rusal of  the  different  treatises,  such  as  those  of  Hughlings  Jackson,  Buzzard,  Broadbent, 
Wilks,  and  others,  will,  however,  show  that  many  cases,  before  they  came  under  these 
observers,  had  been  allowed  to  run  on  for  a  long  time  without  being  recognized,  and 
without  any  specific  treatment  being  attempted ;  one  chief  reason,  perhaps,  being  the 
now  well-established  fact,  that  where  the  syphilitic  poison  selects  as  habitat  the  nervous 
system,  we  have  often  few,  if  any,  secondary  symptoms.  As  a  small  contribution,  there- 
fore^ to  this  very  important  and  highly  interesting  chapter,  I  beg  to  give  an  account  of 
several  cases  observed  by  me,  which  particularly  illustrate  the  varying  of  the  symptoms 
according  to  the  seat  of  the  lesion. 

Case  I. — Emma  H.,  aged  28,  single,  domestic  servant,  was  sent  to  the  Infirmary  as  an 
urgent  case  of  brain  fever,  and  admitted  under  my  care  (in  the  absence  of  Dr.  W. 
Roberts)  on  April,  22,  1874.  I  saw  the  patient  on  the  morning  following.  Without 
being  comatose,  the  patient  was  apathetic  and  taciturn,  complaining  only  of  great  pain 
at  the  back  of  the  head.  From  her  mistress,  who  had  accompanied  her  to  the  hospital, 
we  gathered  that  she  had  complained  for  a  fortnight  of  great  pain  in  the  head ;  this  was 
accompanied  by  a  weakness  in  her  right  arm  and  leg,  which  increased  to  such  an  extent 
that  she  was  obliged  to  take  to  her  bed  four  days  before  admission ;  the  day  before  ad- 
mission the  headache  got  much  worse,  vomiting  came  on,  and  she  felt  so  prostrate  that 
the  family  medical  adviser  sent  her  to  the  hospital. 

The  patient  is  of  middle  height,  dark-complexioned,  and  of  sallow  hue;  her  skin  hot 
and  perspiring  freely;  temp.  101.5°,  pwlse  no,  resp.  24  per  minute.  No  nodes  on  any 
part  of  head  or  body  ;  no  rash  or  cicatrices  on  the  body  ;  the  pupils  a  little  dilated,  equal 
and  reacting  to  light;  hearing  good;  speech  has  nasal  character,  as  if  some  defect  in 
palate ;  no  paralysis  of  the  oculo-motor  muscles ;  no  facial  paralysis ;  tongue  put  out 
straight,  moist,  covered  with  a  thin  fur.  Bowels  had  acted  several  times  during  the  night 
(patient  had  received  a  saline  mixture  on  admission).  Urine  high-colored,  sp.  gr.  1022, 
no  albumen,  abundant  phosphatic  deposit.  Physical  examination  of  chest  and  abdomen 
reveals  nothing  abnormal.  Spine  not  tender  on  pressure ;  the  right  arm  and  right  leg 
completely  paralyzed.  No  wasting  of  right  side.  Sensibility  on  right  side  intact,  like- 
wise electro-contractility  and  electro-sensibility  and  sensibility  to  pain  and  to  temperature. 
The  left  arm  and  leg  in  no  way  affected.     Total  loss  of  appetite ;  great  thirst. 


3l6  PSYCHOLOGICAL   MEDICINE. 

The  age  of  the  patient,  and  the  hemiplegia  pi-eceding  the  purely  inflammatory  symp- 
toms of  the  meninges,  made  me  at  once  suspect  a  specific  cause,  and  I  prescribed  lo  grs. 
of  pot.  iod.  pro  dos.,  together  with  cold  applications  to  head. 

April  23.  Evening.     Patient  in  about  the  same  condition.     Pulse  112,  temp.  100.8°. 

April  24.  Morning.  Patient  passed  a  very  bad  night.  She  had  been  very  restless, 
tossing  about  in  bed,  and  delirious ;  complains  of  most  violent  pains  in  the  head ;  pulse 
100,  temp.  101°.  Mr.  Windsor  kindly  examined  the  eyes,  and  found  the  fundus  nor- 
mal. On  examining  the  throat,  the  soft  palate  is  found  to  be  altogether  absent,  likewise 
the  right  tonsil.  The  pot.  iod.  was  increased  to  20  grs.  pro  dos.,  pil.  Plummeri  (gr.  v.) 
one  every  two  hours. 

Evening.  Patient  worse  ;  semi-comatose ;  passes  fseces  and  urine  involuntarily ;  twitch- 
ings  of  muscles  of  left  side  ;  pulse  thin,  108;  temp.  101.6°;  resp.  hurried  and  shallow. 
Treatment  continued;  mercurial  inunction  applied  to  both  legs. 

April  25.  Patient  considerably  better;  her  features  present  a  more  cheerful  aspect ;  has 
no  recollection  of  what  happened  during  the  last  twenty-four  hours;  pulse  100,  tem.  99.6°. 
Is  able  to  use  her  right  arm  and  leg  a  little ;  pain  in  head  less  severe  ;  complains  of  pain 
in  throat ;  paralysis  of  the  sphincter  continues.  Treatment  continued  ;  chlorate  of  pot- 
ash gargle.  Patient  is  now  for  the  first  time  able  to  give  her  history.  Has  enjoyed 
good  health  till,  twelve  months  ago,  she  suffered  from  headache,  rash,  and  sore  throat, 
the  throat  continuing  to  remain  sore  for  several  months ;  for  the  last  two  months  suffered 
from  pain  in  the  head,  which  was  worse  at  night;  a  fortnight  ago  began  to  lose  power 
in  right  leg  and  arm,  which  increased  till  that  side  was  rendered  perfectly  useless. 

April  26.  Improvement  continues ;  temp.  98.6°,  pulse  80;  has  now  control  over  the 
sphincters. 

The  headache  and  hemiplegia  from  this  time  improved  rapidly ;  she  continued  to  take 
the  pot.  iod.  and  the  mercury,  and  the  induced  current  was  applied  to  the  right  leg  and 
arm.  She  was  sent  to  the  Convalescent  Hospital  on  May  16,  preserving  as  the  only 
remains  of  her  illness  a  slight  dragging  of  right  leg;  she  stopped  for  three  weeks  at  the 
Convalescent  Hospital ;  when  she  left,  the  dragging  of  right  leg  still  persisted,  and  I  have 
heard  nothing  further  from  her  since. 

There  can  be  no  doubt  that  we  had  to  do  here  with  a  case  of  syphilitic  meningitis ;  the 
case,  however,  is  instructive  in  several  respects.  The  syphilitic  disease  ran  its  course  in 
a  very  short  time,  and  within  twelve  months  from  the  first  appearance  of  the  secondary 
symptoms  we  witnessed  the  destruction  of  the  soft  palate  and  the  right  tonsil,  and  the 
advent  of  the  graver  nervous  lesions,-  which  began  with  intense  headache  and  right  hemi- 
plegia. As  regards  the  nature  and  seat  of  lesion,  it  is  more  than  probable  (from  the  fact 
that  the  nervous  troubles  came  on  soon  after  the  syphilitic  infection,  that  the  symptoms 
were  ushered  in  by  great  headache,  that  the  development  and  disappearance  of  the  symp- 
toms were  very  rapid,  and  that  the  other  symptoms  pointing  to  a  gummatous  tumor  of  the 
brain  were  absent)  that  we  had  here  at  first  a  diffuse  inflammatory  disease  in  a  cranial 
bone  of  the  left  base,  which,  by  its  compression  of  the  right  motor  tract,  gave  rise  to  the 
hemiplegia,  and  which,  by  its  extension  to  the  coverings  of  the  brain,  brought  on  the 
general  meningitis.  A  peculiarity  which  is  noticeable  in  this  case  is  the  relation  of  the 
pulse  and  -temperature  to  the  general  symptoms,  the  temperature  being  much  lower  and 
the  pulse  showing  besides  a  greater  constancy  than  is  found  in  simple  meningitis.  In  a 
case  somewhat  similar,  but  much  slighter,  quoted  by  Poncet  [Annales  de  Dermatologie  et 
de  Syphilographie,  4"°°  annee.  No.  3),  the  temperature  ranged  between  98°  and  99.7°)  and 
the  pulse  never  exceeded  92.  Should  this  be  found  constantly  we  should  have  another 
important  aid  in  distinguishing  syphilitic  from  simple  meningitis.  The  paralysis  of  the 
sphincters  marked  the  gravity  of  .the  case  (in  the  lighter  forms  of  cerebral  syphilis  con- 


MODERN    NERVOUS    DISEASE.  317 

stipation  and  slight  retention  of  urine  are  generally  observed)  ;  for,  as  in  all  other  ner- 
vous affections,  they  occur  in  syphilitic  nervous  diseases  in  the  last  stage,  and  out  of 
twenty-five  cases  which  I  collected  from  different  authors,  where  there  was  such  a  condi- 
tion of  things,  sixteen  terminated  fatally. 

If,  for  a  moment,  we  consider  the  different  aids  we  have  in  diagnosing  the  syphilitic 
nature  of  a  nervous  disease,  we  have  the  following  : 

1.  Age  of  patient.  The  age  of  persons  affected  with  syphilitic  nervous  disease  ranges 
between  25  and  40  ;  out  of  ninety-six  cases  collected  by  Braus,  sixty  were  of  patients  be- 
tween 20  and  40  years  old ;  and  the  cases  given  by  Broadbent,  Buzzard,  and  others 
exhibit  the  same  proportions. 

2.  A  syphilitic  history.  We  have  here  to  bear  in  mind  that  it  is  often  difficult,  espe- 
cially in  women,  to  trace  such  a  history;  that  often  when  the  syphilitic  virus  selects  for 
its  locality  the  nervous  system  there  are  few,  if  any,  secondary  symptoms,  vi^hile,  on  the 
other  hand,  nervous  troubles  coming  on  in  a  syphilitic  patient  may  be  simply  due  to  a 
coincidence.  On  looking  over  many  recorded  cases  I  find  that  certain  forms  of  syphilitic 
nervous  disease  are  much  oftener  preceded  by  well-marked  secondary  symptoms  than 
others;  this,  for  instance,  is  true  for  syphilitic  epilepsy  and  the  more  acute  cases  of  men- 
ingitis which  come  on  soon  after  infection. 

3.  Multiplicity  of  lesion.  Nervous  symptoms  which  can  only  be  accounted  for  by  the 
assumption  of  separate  pathological  products  situated  in  different  parts  of  the  nervous 
system  are  almost  always  due  to  syphilis. 

4.  Absence  of  other  causes.  This  applies  particularly  to  the  paralysis  of  the  different 
cranial  nerves  and  to  sudden  attacks  of  hemiplegia  in  young  persons,  in  the  absence  of 
any  cardiac  or  renal  troubles. 

5.  Influence  of  anti-syphilitic  treatment.  In  a  great  many  cases,  especially  where  the 
course  of  the  nervous  disease  is  acute,  and  where  the  patient  has  not  previously  under- 
gone an  anti-syphilitic  treatment  the  effects  of  the  iodide  and  the  mercury  are  very  marked. 
In  the  more  chronic  cases,  however,  where  the  syphilitic  deposit  has  itself  undergone 
degenerative  changes,  and  has  established  secondary  changes  in  the  surroiinding  nerve- 
matter,  the  treatment  will  of  necessity  be  of  little  avail. 

Having  diagnosed  a  nervous  lesion  to  be  syphilitic,  it  becomes  then  of  some  moment 
to  determine  the  exact  nature  and  seat  of  the  affection.  This,  though  important  as 
regards  the  prognosis  of  the  case,  is  of  no  great  weight  as  regards  the  treatment.  I  hope, 
however,  at  a  future  period  to  refer  to  this  point  also. 

The  early  manifestations  of  nervous  syphilis  are  too  much  neglected, 
and  we  deem  it  of  special  importance  to  call  attention  to  this  class  of 
neuroses.  Dr.  Charles  Mauriac,  of  Paris,  in  his  able  work  on  this 
subject,  has  drawn  some  valuable  conclusions,  to  which  we  would 
invite  the  general  practitioner's  study : 

(i.)  At  a  period  very  near  in  point  of  time  to  the  primary  infection,  syphilis  may  in- 
vade the  nervous  centres. 

(2.)  The  early  cerebro-spinal  syphiloses  are  those  that  develop  during  the  virulent 
period  of  the  disorder;  that  is,  during  the  first  two  or  three  years  after  infection. 

(3.)  There  aF«.degrees  in  the  precocity  of  cerebro-spinal  syphiloses :  Those  of  the 
first  degree  are  those  that  make  their  appearance  within  the  first  twelve  months ;  the 
second  degree  includes  those  that  develop  in  the  second  and  third  year  of  the  constitu- 


3l8  PSYCHOLOGICAL    MEDICINE." 

tional  malady.     Statistics  seem  to  sliow  that  those  of  the  first  are  more  frequent  than  those 
of  the  second,  but  these  results  are  not  extremely  important. 

(4.)  Among  the  early  visceral  determinations  of  sj^hilis,  the  cerebro-spinal  are  incom- 
parably the  most  frequent. 

(5.)  They  are  also  the  most  dangerous.  Their  gravity  is  not  at  all  in  direct  proportion 
to  their  diathetic  age ;  those  that  occur  during  the  first  months  of  syphilis  are  as  serious 
as  those  that  appear  in  the  latest  stages. 

(6.)  All  the  forms,  degrees,  and  phenomenal  combinations  that  constitute  the  S3'mp- 
tomatology  and  processes  of  these  S3"philitic  determinations  to  the  ner\'ous  axis  are  as 
•well  seen  in  the  early  cerebro-spinal  syphiloses  as  in  the  later  ones. 

(7.)  There  are,  nevertheless,  some  symptomatic  formulae  that  appear  to  predominate. 
The  most  frequent  are  those  that  consist  in  an  attack  of  hemiplegia  involving  all  one  side 
of  the  body. 

(8.)  Among  the  attacks  of  hemiplegia  those  constituted  by  the  s}Tnptoms  of  aphasia 
with  right  hemiplegia  exceed  in  number  all  the  others. 

(9.)  The  paralytic  forms  are  much  more  numerous  than  the  convulsive  or  epileptic 
forms  in  precocious  cerebral  syphilis. 

(10.)  In  the  cerebro-spinal  syphiloses,  psychic  disorders  and  incoordination  of  move- 
ment are  never  systematized  as  in  insanity,  general  paralysis,  and  locomotor  ataxia. 

(11.)  The  absence  of  systematization  in  the  cerebro-spinal  syphiloses  should  be  regarded 
as  one  of  their  chief  characteristics.  The  only  exception  is  aphasia  with  right  hemi- 
plegia. 

(12.)  Early  determinations  of  s}-philis  to  the  spinal  cord  are  much  less  frequent  than 
those  to  the  brain. 

(13.)  Circumscribed  or  diffuse  hyperplastic  suffusions,  but  rather  circumscribed  in  the 
cortical  layers  of  the  brain  and  in  the  pia  mater,  syphilitic  alteration  of  the  Sylvian  arte- 
ries and  consecutive  ischsemic  softening,  such  are  the  lesions  that  appear  to  belong  to 
precocious  cerebral  syphilis. 

(14.)  In  some  cases  of  early  cerebral  syphilis,  followed  by  death,  we  find  no  lesion,  but 
then  we  do  not  thoroughly  understand  the  arterial  sj^hilosis.  It  may  be  presumed  that 
death  was  the  result  of  a  sudden  anaemia,  extinguishing  at  once  the  nuclei  of  inner^^ation 
of  the  centres  indispensable  to  life. 

(15.)  Onl)'  vague  conjectures  are  possible  as  to  the  etiology  of  precocious  cerebral 
syphilis.  In  the  majority  of  cases  the  primary'  symptoms,  as  well  as  the  subsequent  cuta- 
neous and  mucous  manifestations,  were  very  mild. 

(16.)  The  general  progress  of  the  consritutional  disease  is  not  modified  by  the  appear- 
ance of  precocious  syphilitic  accidents  of  the  nerve  centres.  The  other  manifestations 
are  produced  before,  after,  or  during  the  involvement  of  the  ner\-ous  axis,  without  under- 
going any  change  in  their  forms,  their  degrees,  their  progress,  or  their  topography. 

(17.)  The  precocity  of  cerebro-spinal  sj^hiloses  furnishes  no  particular  indications  as 
regards  treatment.  \Yhatever  the  age  of  the  constitutional  disease,  the  manifestations  in 
the  nervous  centres  demand  the  same  specific  treatment.  The  circumstances  proper  to 
the  determination  itself  furnish  the  secondary  indications  relative  to  the  choice,  dose,  and 
combinations  of  the  two  specific  agents.* 

*  We  would  also  refer  the  student  and  general  practitioner  to  the  work  on  cerebral 
syphilis  by  Dr.  Alfred  Foumier,  of  Paris,  published  in  1879,  ^7  Masson.  He  says  that 
cerebral  troubles  occur  most  often  from  three  to  eighteen  years  after  the  initial  ulcer. 
He  recommends  early  and  energetic  treatment,  kept  up  with  tee  original  energy'  during 

he   coui-se,  and  continued  for  a  long  time  after  the  disappearance  of  symptoms.     He 


DEVELOPMENT    OF    THE    NERVOUS    SYSTEM    BY    EVOLUTION.  3I9 


CHAPTER  XVIII. 

GENERAL  CONSIDERATIONS  ON  THE  DEVELOPMENT  OF  THE  NERVOUS 
SYSTEM  BY  EVOLUTION,  AND  ITS  CONDITION  IN  HEALTH  AND  DIS- 
EASE, AND  REMARKS  ON  THE  REGIONAL  DIAGNOSIS  OF  SPINAL 
CORD    AND    BRAIN    LESIONS. 

A  DIFFERENTIATED  nervous  apparatus  first  shows  itself,  according 
to  Mr.  E.  Wooten,  in  the  ascidian  mollusc.  It  consists  of  one  gan- 
glion, situated  in  the  neighborhood  of  the  mouth,  in  the  mantle,  and 
giving  off  cords  which  proceed  to  the  sense  and  digestive  organs, 
the  muscular  sac,  and  both  orifices.  Next  in  order  come  the  cteno- 
phora,  in  which,  in  the  end  farthest  removed  from  the  mouth,  is  the 
ctenocyst,  a  spherical  vesicle.  This  is  a  sense  organ,  and  rests  on  a 
ganglion  giving  off  fibres.  Next  come  the  echinoidea,  where  there 
is  a  ganglionated  cord  surrounding  the  gullet  and  sending  off  five 
branches  among  the  ambulacral  spaces.  The  annulosa  have  a  chain 
of  ganglia  running  the  whole  length  of  the  body  and  united  by  ner- 
vous cords.  At  one  end,  where  the  sense  organs  are  situated,  the  last 
post-oesophageal  ganglion  gives  off  two  cords,  which  pass,  one  on 
either  side  of  the  oesophagus,  and  enter  each  a  pre-oesophageal  gan- 
glion— the  cephalic — which  ganglion  is  generally  double.  The  high- 
est members  of  the  order  of  the  annulosa — the  insecta — have  two 
cords  passing  backwards  from  the  cephalic  above  the  ventral  ganglia, 
and  giving  off  branches  to  them  and  the  body  walls.  This  is  the 
most  rudimentary  form  of  the  cerebro-spinal  system.  In  the  verte- 
brata  we  have  a  vertebral  column. 

The  lancelet  is  the  vertebrate  with  the  simplest  nervous  system. 
The  neural  axis  of  the  animal  is  a  delicate  tract  of  nucleated  cells 
surrounded  by  a  covering  of  pia  mater.  Fifty  or  sixty  pairs  of 
nerves  are  given  off  laterally.     The  lampreys  and  hogfishes  have  a 

used  iodide  of  potassium  and  mercury,  the  latter  preferably  by  immctions,  and  advises 
alternate  medication.  As  auxiliary  means,  cold  douches  are  verj'  valuable.  The  iodide 
he  gives  at  first  in  a  dose  of  3  grammes  per  day,  raising  it  finally  to  6,  8,  or  even  10 
grammes  daily.  Strict  hygiene  is  to  be  observed.  No  venereal  indulgence  or  brain- 
work.  Fournier  ranges  the  various  symptoms  of  cerebral  syphilis  under  the  headings  of: 
I.  The  cephalic;  2.  Congestive;  3.  Convulsive  or  epileptic;  4.  Aphasic  ;  5.  Mental; 
and  6.  Paralytic  group. 


320  PSYCHOLOGICAL    MEDICINE. 

higher  nervous  organization  than  the  lancelet,  as  they  have  a  carti- 
laginous cranium,  and  the  spinal  cord  extends  anteriorly.  There  is 
no  bony  spinal  column.  In  the  cod  and  the  shark,  the  posterior  fis- 
sure widens  and  the  halves  of  the  cord  expand.  Two  lateral  columns 
also  project  into  the  ventricle  from  the  conjoined  restiform  and  pos- 
terior pyramidal  tracts. 

We  next  get  a  cerebellum  and  crura  cerebelli  added.  Primarily 
in  the  brain  we  have  a  medulla,  a  cerebellum,  and  one  or  two  unim- 
portant appendages.  Relatively  it  is  higher  and  more  complex  in 
fishes  than  in  the  higher  vertebrates.  The  brain  is,  to  all  intents  and 
purposes,  the  developed  cephalic  portion  of  the  cord.  Secondarily 
we  have  the  optic  lobes,  which  is  the  largest  division  in  osseous 
fishes.  Under  the  lobes  are  two  sub-spherical  bodies,  separated  by 
walls  containing  a  cavity  which  is  analogous  to  the  third  ventricle  of 
the  brain  in  man.  This  ventricle  is  prolonged  downwards  into  the 
pedicle  of  the  pituitary  gland,  and  upward  into  that  of  the  pineal 
gland.  The  brain  of  a  crocodile  is  very  small,  not  much  larger  than 
a  human  thumb,  while  the  brain  of  a  bird  is  larger,  both  laterally 
and  vertically,  but  is  composed  principally  of  the  optic  lobes  and  the 
cerebellum.  The  brain  of  the  dog  and  of  other  animals  is  larger 
anteriorly,  and  the  cerebra  have  developed  pari  passu  with  the  ani- 
mal's degree  of  intelligence;  and  this  rule  is  observed  in  the  human 
race,  the  complexity  of  the  brain  being  in  direct  relation  to  the  de- 
gree of  intelligence  of  the  people. 

Multiplication  of  ganglia,  as  for  instance  in  the  actinidse,  is  always 
accompanied  by  a  corresponding  differentiation  of  ganglionic  func- 
tions, some  being  devoted  to  sight,  others  to  controlling  muscular 
tissue,  etc.  The  nervous  system  is  always  adapted  to  the  general 
structure  of  the  animal.  The  nervous  system  of  the  annulosa  con- 
sists of  the  double  chain  of  ganglia  which  I  have  described.  The 
greatest  number  of  these  ganglia  are  post-cesophageal,  representing 
the  sympathetic  of  the  higher  animals.  The  pro-cesophageal  gan- 
glion, being  situated  on  the  superior  surface  of  the  digestive  tube,  is 
the  direct  homologue  of  the  vertebrate  brain.  The  insecta — which 
are  the  most  important  members  of  this  order — exhibit,  as  I  have 
said,  the  most  rudimentary  form  of  a  cerebro-spinal  axis.  There  is 
a  prolongation  of  the  substance  of  the  cephalic  ganglion  backward 
in  the  form  of  two  cords  above  and  in  contact  with  the  non-cephalic 
ganglia.  Functionally,  these  spinal  fibres  unite  the  ganglia  and 
fibres  into  a  mechanism  capable  of  responding  to  the  mandates  of 


DEVELOPMENT  OF  THE  NERVOUS  SYSTEM  BY  EVOLUTION.    32 1 

any  one  ganglion,  but  more  especially  to  the  cephalic.  If  we  cut  an 
annulose  animal,  such  as  the  garden-worm,  for  instance,  into  pieces, 
each  piece  will  retain  the  power  of  movement  for  hours,  provided 
that  each  piece  has  a  perfect  ganglion.  The  garden-worm  has  no 
spinal  fibres.  If  I  take  an  insect,  such  as  a  fly,  and  cut  off  its  head, 
it  can  fly  a  little,  can  walk,  can  regain  its  footing  if  I  put  it  on  its 
back.  But  if  I  cut  it  in  two,  it  dies, — why?  Because  while  in  the 
worm  the  separate  pairs  of  ganglia  formed  an  independent  vital  appa- 
ratus, in  the  fly  they  are  not  independent,  but,  through  the  fly's  spinal 
fibres,  interdependent.  In  the  highest  vertebrates,  reflex  movements 
may  take  place  through  the  brain,  spinal  cord  and  sympathetic  sys- 
tem. These  govern  the  visceral  functions  and  are  connected  with 
the  voluntary  actions  of  life.  I  have  shown  how  the  brain  or  cephalic 
ganglion  is  gradually  increased  in  motor  and  sensory  power  and 
the  non-cephalic  ganglion  relatively  lessened,  the  nervous  apparatus 
gradually  gaining  in  complexity  until  man  is  reached,  where  we  find 
the  nervous  system  comprising  the  cerebrum  and  cerebellum,  with 
the  various  ganglia  and  commissures  which  belong  to  these  bodies, 
the  medulla  oblongata,  the  spinal  cord,  the  sympathetic  ganglia  and 
the  nerves,  which  springing  from  these  several  sources  are  distribu- 
ted throughout  the  organism.  In  the  insect  the  spinal  cord  is  a  centre 
of  common  sensation,  and  it  acts  by  itself  without  the  brain.  It  acts 
as  a  whole,  and  section  causes  death. 

Another  very  interesting  fact  is  that  the  fineness  of  the  nerve-fibre 
in  man  is  in  direct  relation  to  the  dignity  of  its  functions.  The 
nerve-fibres  in  man,  in  the  brain  and  spinal  cord,  measure  from  j^'^j^ 
to  y^g-Qo"  ^^  ^"^  '\x\q\\.  in  diameter,  and  in  the  trunks  and  branches  of 
nerves  they  measure  from  ^-^^q-  to  3 q-'oo-  in.  In  the  mammalia  the 
average  size  of  the  nerve-fibres  is  from  -^-^^-^  of  an  inch  in  diameter 
to  6?(j(7-  I'^  the  frog  yj'eo-  to  j^g-jj-,  and  in  the  eel  ygVg  of  ^n  inch. 
Among  the  invertebrates  the  fibres  are  relatively  fewer  and  coarser 
than  in  the  vertebrates,  and  the  fibres  of  the  cephalic  ganglion  are 
finer  than  those  of  nerve  branches.  We  can,  therefore,  judge  pretty 
nearly  about  the  relative  powers  of  parts  of  any  animal's  nervous 
system  by  comparing  the  size  of  their  fibres.  We  see,  therefore, 
through  all  the  members  of  the  animal  kingdom  which  possess  a 
nervous  system,  a  process  of  evolution  or  development  gradually 
proceeding,  with  a  gradual  differentiation  of  nervous  cords  to  separate 
fibres;  that  we  have,  primarily,  multiplication  of  ganglia  and,  as  the 
next  step  in  evolution  or  development,  the  supremacy  of  a  single 


322  PSYCHOLOGICAL    MEDICINE. 

ganglion  which  becomes  the  cephahc  ganglion,  and  that  next  this 
cephalic  ganglion  sends  backwards  two  communicating  cords,  and 
we  have  a  gradual  elaboration  of  the  cerebro-spinal  axis.  We  should 
bear  in  mind  that  the  qualities  of  the  tissues  of  the  highest  vertebrates 
are  the  differentiated  properties  of  the  simpler  protoplasmic  cell.  If 
we  find  but  a  single  ganglion  in  an  animal,  we  know  that  in  it  re- 
sides that  animal's  highest  powers.  If  the  ganglia  are  connected 
with  sense  organs,  we  know  then  that  we  have  an  animal  with  gan- 
glia of  special  sense,  presiding  over  sight,  hearing,  etc.  As  the 
cerebro-spinal  axis  elaborates,  we  have  separate  ganglia  with  distinct 
functions ;  the  spinal  cord  differentiating  in  degree  and  receiving  the 
power  of  reflex  action,  which  increases  with  the  multiplication  of 
sympathetic  ganglia,  losing  gradually  its  facilities  of  common  sensa- 
tion and  volition,  which  become  grouped  in  the  cephalic  ganglion  or 
brain.  The  nervous  system  develops  first  in  the  development  of  a 
large  complex  cephalic  ganglion  and  spinal  cord ;  and  secondarily, 
by  the  extension  into  the  tissues  of  the  body  of  offshoots  from  the 
spinal  cord ;  and  finally,  as  I  have  before  remarked,  as  the  intelli- 
gence increases,  the  fineness  of  the  nervous-fibres  increases. 

Gejieral  Considerations  o?i  the  Diagnosis,  Pathology  and  Treatment 
of  Nervous  Diseases. — There  has  been  a  great  advance  in  the  treat- 
ment of  nervous  diseases  recently,  attributable  to  increased  knowl- 
edge, to  the  improved  methods  of  medical  teaching,  to  the  closer 
attention  paid  to  the  anatomical  investigations,  and  to  more  extended 
opportunities  of  medical  research  offered  by  the  invention  of  the 
precise  instruments  for  diagnosis,  in  which  our  age  has  been  so 
prolific.  The  introduction  of  the  ophthalmoscope  has  thrown  a  much 
desired  light  into  a  heretofore  dark  chamber  of  cerebral  pathology, 
enabling  the  physician  to  infer  from  the  condition  of  the  retinal  ves- 
sels, the  existence  of  structural  changes  in  the  cerebral  arteries  cal- 
culated eventually  to  lead  to  the  host  of  diseases  which  may  threaten 
the  integrity  of  the  vital  and  intellectual  functions,  or  prove  fatal 
perhaps  instantaneously.  Although  not  an  ultra  advocate  of  the 
ophthalmoscope  in  the  diagnosis  of  diseases  of  the  brain  and  spinal 
cord,  I  think  it  is,  in  many  instances,  a  most  useful  adjunct,  and  will 
brieBy  notice  the  cases  in  which,  by  its  aid,  we  may  make  a  more 
accurate  diagnosis  than  would  otherwise  be  possible.  The  great 
point  of  importance  in  the  treatment  of  nervous  diseases  is,  to  be 
able  to  make  an  early  and  accurate  diagnosis  of  the  seat  of  the  lesion 
in  organic  diseases  of  the  brain  and  spinal  cord.     We  want  to  know 


DEVELOPMENT   OF   THE    NERVOUS    SYSTEM    BY   EVOLUTION.  323 

what  the  disease  is  and  where  it  is,  and  if  we  can  relieve  or  cure  it. 
We  must  be  perfectly  informed  as  to  the  physiological  anatomj/  of 
the  brain  and  spinal  cord,  and  also  as  to  its  physiology.  We  must 
also  thoroughly  understand  semeiology,  to  be  experts  in  nervous 
pathology.  We  are  beginning  to  be  able  to  localize  disease  affecting 
only  portions  of  the  brain,  very  accurately.  We  can  also  diagnos- 
ticate lesions  occupying  one-half  of  the  spinal  cord,  and  can  estimate 
accurately  the  height  of  a  lesion  in  the  cord.  We  can  diagnose 
disease  in  the  antero-lateral  columns,  the  posterior  columns,  the  ante- 
rior cornua,  the  centre  of  the  cord,  and  in  the  nuclei  of  the  medulla 
oblongata.  We  can  determine  the  extent  and  exact  distribution  of 
descending  degeneration  in  the  spinal  cord  secondary  to  cerebral 
lesions.  We  can  also  diagnosticate  the  exact  seat  of  disease  of  a 
mixed  type,  as,  for  instance,  amyotrophic  sclerosis,  where  there  exists 
disease  of  the  anterior  matter  of  the  cord  combined  with  sclerosis  of 
the  antero-lateral  column  of  the  cord.  We  have  been  guided  in  our 
studies  on  the  diseases  of  the  spinal  cord  by  embryological  and  mi- 
croscopical researches  as  to  the  structure  of  the  spinal  cord. 

Such  researches  have  taught  us,  among  other  things,  the  law  of 
variability  as  to  the  decussation  of  the  motor  tract  just  below  the  an- 
terior pyramids  of  the  medulla  oblongata,  which  enables  us  to  un- 
derstand those  cases  in  which  a  brain  lesion  on  one  side  of  the  brain 
produces  paralysis  or  spasm  on  the  same  side  of  the  body,  and  also 
should  teach  us,  not  that  there  is  no  decussation  of  the  motor  tract, 
but  that  these  cases  are  exceptional  ones.  For  example,  if  a  patient 
is  brought  to  me  in  consultation,  and  he  has  chronic  localized  con- 
vulsions of  one  side  or  affecting  perhaps  but  one  limb,  I  should  un- 
hesitatingly say  we  had  to  deal  with  a  cerebral  tumor,  in  all  proba- 
bility, in  the  opposite  motor  zone.  The  ophthalmoscope  in  this  case 
would  very  likely  aid  my  diagnosis  by  revealing  a  neuro-retinitis  or 
choked  disk,  and  the  patient  would  also  probably  complain  of  a 
fixed  localized  pain  in  the  head,  while  percussion  over  the  affected 
part  of  the  brain  would  elicit  pain.  In  locomotor  ataxia  or  poste- 
rior spinal  sclerosis,  the  ophthalmoscope  reveals  a  papillary  hyper- 
semia  of  the  optic  nerves  ending  in  atrophy,  although  we  may  find 
posterior  spinal  sclerosis  with  no  lesion  in  the  optic  nerve.  In 
cerebral  tumors,  either  in  the  cerebellum,  the  cerebral  convolutions, 
or  in  the  basal  ganglia  of  the  brain,  we  find  by  ophthalmoscopic  ob- 
servation, generally,  a  descending  optic  neuritis  or  a  choked  disk. 

Basilar  Meningitis,— ll\i^  ophthalmoscope  aids  our  diagnosis  in  that,. 


324  PSYCHOLOGICAL   MEDICINE. 

a  choked  disk  or  a  neuro-retinitis  with  exudation,  directs  our  atten- 
tion to  intracranial  disease  of  some  kind,  and  we  must  look  to  the 
other  symptoms  to  help  us  locate  the  disease  in  the  nervous  system. 
Generally,  grave  lesions  of  the  brain  and  spinal  cord  cause  a  propa- 
gation of  the  lesion  to  the  eye,  giving  rise  to  neuritis  or  neuro-reti- 
nitis or  choroiditis.  The  neuritis,  when  it  occurs,  may  be  either  me- 
chanical, depending  on  obstruction  and  arrest  of  meningeal  circula- 
tion ;  a  descending  neuro-retinitis,  which  we  find  in  acute  and  chronic 
encephalitis  and  in  intracranial  tumors  ;  an  ascending  neuritis,  as- 
cending in  the  direction  of  the  inflammatory  process  in  the  nerve-fibres 
of  the  spinal  cord  [jiot  the  ascending  optic  neuritis  of  the  ophthalmol- 
ogists, which  means  a  neuritis  starting  from  the  ocular  end  of  the 
optic  nerve,  ascending  towards  the  brain) ;  and  finally,  a  constitu- 
tional neuro-retinitis  or  neuro-choroiditis,  found  in  syphilis  of  the 
brain  and  cord.  We  must  bear  in  mind  that  grave  cerebral  or 
spinal  disorder  may  exist  with  no  apparent  ophthalmoscopic  sign  be- 
ing present.  The  presence  of  amblyopia  and  amaurosis,  choked 
disk  and  optic  neuro-retinitis,  may  support  a  diagnosis  of  cerebellar 
disease,  but  we  should  also  find  the  positive  symptoms  of  disturb- 
ances of  co-ordination,  especially  the  reeling  gait  with  severe  vertigo, 
and  even  then,  as  we  find  these  symptoms  in  other  nervous  disor- 
ders, they  are  not  perfectly  pathognomonic  of  cerebellar  disease. 

Disease  of  the  anterior  pair  of  the  tubercular  quadrigemina  is  gen- 
erally accompanied  by  disease  of  visual  power  or  bhndness.  Al- 
though optic  neuritis  may  be  wanting  in  large  tumors  of  the  brain, 
we  may  find  it  with  very  small  neoplasms,  if  they  are  complicated 
with  hydrocephalus  of  an  extensive  character.  The  hydrocephalus 
produces  optic  neuritis  by  the  cerebral  oedema  it  excites.  If  we  find 
an  oedematous  optic  neuritis,  we  are  justified  in  diagnosticating  the 
existence  of  hydrocephalus  and  cerebral  oedema.  Retinal  ischsemia 
and  chronic  spasm  of  the  iris  would  seem  to  bear  a  pretty  definite  re- 
lation to  epilepsy,  although  more  positive  results  are  hoped  for  in 
the  future  from  more  extended  investigations  on  this  point.  Inju- 
ries to  the  head  have  also  been  followed  by  a  choked  disk,  indica- 
tive of  grave  cerebral  trouble.  Finally,  by  the  aid  of  the  ophthalmo- 
scope, we  may  be  much  assisted  in  making  an  early  and  accurate 
diagnosis  of  diseases  of  the  brain  and  spinal  cord.* 

*  In  chorea,  reports  have  been  made  of  embolism  of  the  central  artery  of  the  retina. 
We  see  optic  neuritis  in  cases  of  convulsions  from  organic  brain-disease.  We  find  atro- 
phy of  the  optic  nerve  in  paralytic  dementia.    Optic  nerve  atrophy  is  also  seen  in  the  early 


DEVELOPMENT    OF   THE    NERVOUS    SYSTEM    BY   EVOLUTION.  325 

Cerebral  Localization. — Respecting  the  very  interesting  subject  of 
cerebral  localization,  it  is  regarded  as  settled  that  the  ascending  pa- 
rietal convolution  is  the  cortical  motor  centre,  in  its  innermost  and 
superior  part,  of  the  upper  and  lower  limbs ;  in  its  middle,  for  the 
forearm  and  hand ;  and  in  its  external  or  inferior  part,  of  the  facial 
muscles.  The  ascending  frontal  convohition  is  the  cortical  motor 
centre,  in  its  most  external  or  inferior  part — where  the  third  frontal 
has  its  origin-^— of  the  lips  and  tongue,  the  movements  of  which 
are  destined  for  the  pronunciation  of  words,  and  we  generally  find 
a  perfect  parallelism  between  the  intensity  of  the  lesion  of  move- 
ments and  the  gravity  of  the  lesion  in  the  cortical  motor  zone.  There 
is  generally  a  perfect  accord  between  the  cortical  lesion  and  the  pe- 
ripheral and  functional  lesion,  so  that,  for  instance,  in  a  case  of  lo- 
calized convulsions,  we  may,  with  certainty,  y9<?OT  the  region  of  the  body 
wJiere  tlie  convidsive  movejnents  commence^  diagnosticate  the  cortical 
centre  primitively  and  principally  affected,  which  will  be  that  corre- 
sponding to  the  group  of  muscles  earliest  brought  into  action. 

We  know,  absolutely,  that  in  a  case  of  verbal  paralysis  we  have  a 
lesion  of  the  most  inferior  part  of  the  ascending  frontal  convolution 
and  of  the  foot  of  the  third  frontal,  in  which  cortical  centres  "  the 
transformation  of  ideas  and  verbal  images  into  motor  impulses  to- 
ward the  muscles  destined  for  their  extrinsication  takes  place." 

Respecting  the  cerebral  ganglia,  we  know  that  the  corpora  quad- 
rigemina  serve  as  nervous  centres  for  the  perception  of  light,  and 

stages  of  locomotor  ataxia  in  some  cases,  also  in  disseminated  sclerosis.  If  a  traumatic 
meningitis  occurs  after  an  injury  to  the  head,  we  tnay  have  an  optic  neuritis,  or  it  may  oc- 
cur after  some  time,  as  the  result  of  inflammation.  A  meningitis  of  the  convexity  would 
not  probably  reveal  any  eye  lesions. 

As  the  retinal  circulation  is  regulated  in  a  special  manner  by  the  intra-ocular  tension, 
the  student  must  not  expect  to  find  anaemia  and  hypergemia  of  the  brain,  always  showing 
itself  by  a  corresponding  change  in  the  retinal  circulation.  Congestion  of  the  optic  pa- 
pillae will  generally  follow,  however,  very  acute  cerebral  hypersemia.  Gowers  has  stated 
that  in  chronic  encephalitis,  we  may  see  well-marked  neuritis  (papillitis).  My  friend, 
Dr.  H.  Knapp,  the  eminent  ophthalmologist,  recently  sent  me  a  case  in  which  retinal 
hsemorrhage  preceded  for  a  short  time,  a  fatal  cerebral  haemorrhage.  The  blood  state 
was  bad,  the  patient  being  addicted  to  alcohol.  Gowers  states  that  we  may  in  rare  cases 
see  retinal  embolism  in  softening  from  embolism;  also,  that  in  softening  from  arterial 
thrombosis,  when  this  is  due  to  atheroma,  associated  changes,  hsemorrhages  or  renal  reti- 
nitis, may  be  found  in  the  retina.  In  cerebral  abscess,  we  may  find  an  optic  neuritis, 
also  in  most  cases  of  brain  tumor.  In  opium  habitues,  I  have  seen  optic  nerve  atrophy 
and  also  congestion  in  inebriates.  Care  must  be  taken  not  to  confound  physiological 
variations  with  pathological  changes.  In  diseases  of  the  nervous  system,  science  would 
be  much  advanced  if  physicians  would  examine  and  report  all  intra-ocular  changes. 


326  PSYCHOLOGICAL    MEDICINE. 

that  a  reflex  action  takes  place  throug-h  them  by  which  the  amount 
of  light  admitted  to  the  eye  is  regulated  to  accommodate  the  sensi- 
bility of  the  pupil.  The  optic  thalami  receive,  preserve,  and  trans- 
form the  sensorial  impressions  previous  to  their  definite  irradiation 
to  the  cortical  peripher}^ 

The  corpora  striata  are  the  centre  for  the  reception,  regulation, 
and  elaboration  of  voluntary  motor  impressions  emanating  from  the 
deep  layers  of  the  cortical  matter,  whose  large  cells  originate  them. 

With  regard  to  therapeutical  appliances,  a  complete  revolution  has 
been  wrought  in  the  treatment  of  cerebral  disease  by  the  guidance  of 
the  scientific  principles  and  instruments  I  have  spoken  of.  Every 
neurologist  will  admit  that,  in  many  respects,  however,  the  pathology 
of  cerebral  disease  is  still  involved  in  great  obscurity,  although  mod- 
ern physiological  research  and  clinical  experience  have  done  much 
to  remove  many  difficulties  from  our  path.  We  may  have  many 
serious  cerebral  diseases  existing,  and  even  reaching  a  fatal  termina- 
tion, without  giving  any  appreciable  note  of  warning  and  unaccom- 
panied by  any  pathological  symptoms  during  life ;  and,  on  the  other 
hand,  we  may  have  apparently  slight  cerebral  derangement  producing 
serious  and  alarming  symptoms. 

The  exact  seat  of  cerebral  disease  is  indicated  more  or  less  clearly 
according  to  its  more  or  less  intimate  connection  with  the  nervous 
fibres  which  control  or  direct  the  communications  between  the  cere- 
bral mass  and  those  external  objects  with  which  our  bodies  are 
placed  in  relation.  In  a  general  way,  we  may  say  that  the  posterior 
columns  of  the  spinal  cord,  passing  through  the  medulla  oblongata, 
through  the  pons  varolii,  then  through  the  ganglia  called  the  optic 
thalami  and  the  corpora  striata,  are  connected  vinth  the  sensitive 
branches  of  the  fifth  pair  of  nerves;  while  the  anterior  columns,  pur- 
suing a  similar  course,  are  connected  with  the  motor  branches  of  the 
fifth  pair,  and  also  with  the  third  pair,  the  fourth  pair,  the  sixth  pair, 
and  the  portio  dura  of  the  seventh  pair  and  the  ninth  pair,  all  of  which 
are  exclusively  endowed  with  motor  powers.  As  we  trace  the  ner- 
vous fibres  of  the  brain  downwards  we  find  them  successively  passing 
through  the  corpora  striata,  the  pons  varolii,  and  then  crossing  or 
decussating  in  the  medulla  oblongata,  so  that  the  fibres  from  the  right 
side  of  the  brain  pass,  for  the  most  part,  to  the  left  side  of  the  cord 
and  vice  versa.  The  explanation  is  thus  afforded  of  the  fact  that 
paralysis  on  one  side  of  the  body  almost  akuays  denotes  some  dis- 
ease on  the  opposite  side  of  the  brain,  and  it  is  also  easy  of  compre- 


DEVELOPMENT   OF   THE    NERVOUS    SYSTEM    BY   EVOLUTION.  32/ 

hension  that,  when  the  central  part  of  the  motor  or  sensitive  tract  is 
affected,  the  paralysis  will  be  on  both  sides.  It  is  a  fact  not  so  gener- 
ally known  that,  when  the  seat  of  the  disease  is  in  that  part  of  the 
brain  which  is  not  immediately  in  the  tract  of  the  motor  or  sensory 
nerves,  there  may  be  no  paralysis  at  all,  although  the  lesion  may  be 
very  serious  and  extensive.  The  great  bulk  of  the  hemispheres  are, 
so  to  speak,  expansions  or  outgrowths  from  the  divergent  fibres  of 
the  spinal  cord,  and  are,  as  it  were,  outside  the  motor  and  sensory 
tracts,  or  are  only  blended  with  them  in  a  loose  and  general  connec- 
tion. I  know  of  a  case  where  there  was,  in  the  right  posterior  lobe 
of  the  brain,  very  near  the  surface,  a  large  cavity — as  large  as  a  hen's 
egg — filled  with  an  apoplectic  clot,  where,  during  life,  there  was  no 
paralysis  in  any  of  the  limbs  and  no  anaesthesia,  although  the  patient 
was  carefully  examined  day  by  day  for  three  weeks  previous  to  death. 
The  symptoms  were  sickness,  vomiting,  great  pain  in  the  head,  the 
pupils  contracted,  bowels  constipated,  and  great  somnolence.  The 
urine  passed  involuntarily.  Nature  was  trying  to  effect  a  cure  in  this 
case,  as  a  membrane  was  in  process  of  formation  on  the  circumference 
of  the  cavity,  and  the  clot  was  beginning  to  assume  a  yellowish  tint. 
The  reason  there  was  no  paralysis  was  because  the  seat  of  the  effu- 
sion was  not  in  the  tract  of  the  ordinary  motor  and  sensory  nerves. 
The  general  location  of  the  apoplectic  effusion  is  in  one  of  the  lateral 
ventricles,  affecting  the  corpora  striata  or  the  optic  thalami. 

There  are  many  circumstances  which  give  us  reason  to  hope  for 
good  results  from  treatment  in  some  cases  of  brain  disease  apparently 
of  the  most  desperate  nature.  We  may  have  symptoms  indicating 
brain  disease  and  the  brain  be  perfectly  healthy,  or  the  brain  may  be 
affected  functionally  and  secondarily,  the  real  seat  of  the  disease 
being  situated  elsewhere,  and  of  a  transient  or  curable  nature. 

I  have  seen  many  cases  where  convulsions,  spasms,  or  coma  ex- 
isted while  the  brain  was  intact,  and  when,  the  local  symptoms  being 
removed,  the  brain  symptoms  disappeared  entirely.  I  have  seen  ap- 
parent apoplexy  depending  on  congestion  of  the  kidneys  and  rapidly 
disappearing  as  such  congestion  was  relieved.  I  have  seen  coma 
and  convulsions  vanish  when  an  intestinal  worm  was  expelled.  I 
have  seen  cerebral  congestion  in  women  disappear  as  the  menses 
appeared  or  reappeared,  and  many  family  physicians  have  seen  spu- 
rious hydrocephalus  disappear  on  the  cutting  of  a  tooth.  But  even 
if  we  have  actual  disease  of  the  brain  it  does  not  follow  at  all  that 
the  case  is  incurable.     Primary  congestion  of  the  brain  is   often 


328  PSYCHOLOGICAL   MEDICINE. 

relieved  by  remedial  dietetic  and  hygienic  measures,  and  even  after 
an  apoplectic  effusion  has  taken  place  nature,  assisted  by  judicious 
treatment,  may  accomplish  a  cure.  Nature  can  absorb  effused  blood, 
leaving  a  cyst,  and  the  brain  may  be  restored  to  its  healthy  state. 
Certainly  an  attack  of  apoplexy  followed  by  paralysis  is  a  very  serious 
state  of  things,  but  life  may  be  preserved  and  enjoyed  for  a  great 
many  years  by  judicious  remedial  measures  and  by  keeping  away  all 
injurious  influences  from  persons  who  have  had  an  apoplectic  attack. 
Such  persons  should  be  put  on  low  diet,  as  a  rule,  and  purgative 
medicines  administered.  I  think  there  is  nothing  better  than  a  drop 
of  croton  oil,  followed  by  saline  purgatives,  with  perhaps  bleeding  if 
the  attack  is  recent,  the  patient  plethoric,  the  pulse  full,  hard,  and 
strong,  and  the  breathing  stertorous.  In  the  most  fortunate  of  these 
cases  we  shall  find  our  patient  much  better,  in  full  possession  of  his 
faculties,  and  with  regained  use  of  his  limbs,  and  we  get  a  complete 
cure.  We  may  find  hypochondriasis,  hysteria,  vertigo,  wakefulness, 
or  drowsiness  all  produced  by  a  long-continued  improper  condition 
of  the  bowels,  from  imperfect  action,  or  a  torpid  condition  of  the 
secreting  and  expelling  structures  of  the  large  bowel. 

If  the  descending  colon  does  not  work  well  we  may  have  quite 
violent  and  persistent  pains  referred  to  the  back,  hips,  or  groins  ; 
also  certain  forms  of  sciatica  and  violent  lumbar  pains.  I  very  often 
find  that  vertigo,  swimming  in  the  head,  or  giddiness  is  indicative 
merely  of  a  deranged  condition  of  the  stomach  and  liver,  or  of  dis- 
turbed heart-action,  although  vertigo  may  be  due  to  serious  brain 
disease.  Persistent  drowsiness  is  generally  dependent  upon  some 
imperfect  action  of  the  digestive  organs,  and  mild  purgation  gener- 
ally relieves  this  troublesome  symptom.  The  symptoms  of  wakeful- 
ness and  restlessness,  when  your  patient  says  he  must  be  constantly 
changing  his  place  or  scene,  and  cannot  get  into  a  composed  state, 
and  cannot  sleep,  should,  if  it  has  lasted  long,  excite  attention.  Rest 
from  business  for  a  few  weeks  will,  in  an  overworked  man,  perhaps 
ward  off  impending  mental  disease. 

The  physician  who  is  interested  in  cerebral  physiology  will  find  it 
a  matter  of  interest  to  institute  experiments  on  the  original  tempera- 
ture of  the  head  under  the  different  conditions  of  rest  and  intellectual 
activity.  It  will  be  found,  as  a  uniform  rule  in  such  researches,  that 
the  evolution  of  heat  is  directly  in  proportion  to  the  intensity  of  men- 
tal action,  and  that  the  anterior  portion  of  the  left  side  of  the  head 
will  show  the  rise  more  frequently  and  to  a  greater  extent  than  any 


DEVELOPMENT    OF   THE    NERVOUS    SYSTEM    BY    EVOLUTION.  329 

other  region,  both  for  intellectual  and  emotional  states.     The  best 
instrument  in  use  is  a  thermo-electric  apparatus. 

In  localizing  chronic  lesions  of  the  nerve-centres,  the  rules  laid 
down  by  Professor  Benedikt,  of  Germany,  are  very  excellent,  and  I 
accordingly  give  them  here  : 

1.  The  appearance  of  synchronous  and  symmetrical  paraplegia  points  to  disease  of  the 
anterior  half  of  the  spinal  cord  or  its  envelope.  Only  very  exceptionally  does  a  spinal 
paraplegia  affecting  the  legs  or  arms  arise  from  two  hemiplegias.  Paraplegia  of  the  legs 
genei-ally  points  to  disease  at  the  level  of  the  lumbar  enlargement ;  paraplegia  of  the 
arms,  to  an  affection  of  the  cervical  enlargement.  Paraplegia  from  disease  of  the  verte- 
bral column  is  characterized  in  its  course  by  the  primary  preponderance  of  the  symptoms 
of  diseased  vertebrae  at  the  seat  of  the  lesion,  and  is  shown  by  the  greater  implication  of 
the  posterior  roots  and  their  long-continued  irritation  in  paraplegic  doidotireiise. 

2.  Cerebral  paraplegia  clearly  arises  from  two  clearly-defined  hemiplegias.  Excep- 
tions due  to  disease  of  the  spinal  cord  are  exceedingly  rare. 

3.  Characteristic  tabetic  symptoms  show  disease  of  the  posterior  half  of  the  spinal 
cord. 

4.  Progressive  muscular  atrophy  shows  disease  of  the  gray  substance  of  the  cord  in  the 
neighborhood  of  the  central  canal,  or,  at  any  rate,  diffused  disease  of  the  anterior  roots 
and  the  accession  of  atrophy  of  the  extremities  to  the  number  of  spinal  symptoms  has  the 
same  significance. 

5.  Hemiplegia,  with  opposite  hemiansesthesia,  points  to  disease  of  one-half  of  the 
spinal  cord.  The  hyperaesthesia,  on  the  same  side  with  the  paralysis,  arises  probably 
from  paralysis  of  the  vaso-motor  nerves  on  the  affected  side. 

6.  Bilateral  tabetic  neuralgia  of  the  legs  or  arms,  in  central  neuroses,  shows  disease  of 
the  posterior  roots  and  their  central  prolongations. 

7.  Progressive  paralysis  of  cerebral  nerves  points  to  a  more  or  less  diffuse  disease  of 
the  region  of  the  medulla  oblongata  containing  their  nuclei  as  far  as  the  crura  cerebri, 
or  diffuse  disease  of  the  peripheral  prolongations  of  these  nuclei. 

8.  Paraplegia  of  the  tongue  (alalia)  and  its  inception  stage  as  well  as  difficulty  of  deg- 
lutition, signifies  a  disease  at  the  level  of  the  hypoglossal  and  glosso-pharyngeal  nuclei. 

9.  Hemiplegia,  with  opposite  facial  or  oculo-motorius  paralysis,  shows  disease  of  the 
fibres  of  the  pyramid  at  the  level  of  the  affected  nuclei,  especially  of  the  points  of  exit 
of  the  affected  nerves. 

10.  Hemiplegia,  with  hemiansesthesia  of  the  same  side,  points  to  disease  of  the  pyra- 
mid between  that  level  in  the  medulla  oblongata  at  which  the  decussation  of  the  sensitive 
fibres  is  accomplished,  and  the  entrance  (inclusive)  of  the  outer  bundle  from  the  foot  of 
the  crura  cerebri  into  the  medullary  substance  of  the  hemisphere  behind  the  lenticular 
nucleus.  Exclusive  hemiansesthesia,  or  where  that  predominates  over  hemiplegia,  points 
by  preference  to  the  latter  spot. 

11.  Hemiplegia,  with  incomplete  facial  paralysis  (the  upper  branch  remaining  free), 
shows  disease  of  the  central  motor  ganglia.  The  electrical  examination,  especially  the 
discovery  of  crossed  reflex  action,  is  of  signification  for  the  localization  of  the  paralysis 
within  the  crura  cerebri  (Gehirnstammes)  and  the  central  ganglia. 

12.  Hemiplegia,  with  convulsions,  points  to  a  lesion  of  the  cerebral  hemispheres  cen- 
tral from  the  central  ganglia.  The  more  the  convulsions  become  prominent  the  nearer 
is  the  locality  to  the  convolutions.     Complication  with  aphasia  (the  ability  to  understand 


330  PSYCHOLOGICAL    MEDICINE. 

speech  remaining),  shows  the  locality  of  the  lesion  to  be  in  the  anterior  lobe  in  the 
neighborhood  of  the  island;  complication  with  bilateral  nemo-retinitis  shows  that  it  is 
above  the  optic  thalamus.  Many  times  the  convulsions  do  not  appear  in  disease  of  the 
hemispheres  with  hemiplegia,  because,  on  one  hand,  with  the  occurrence  of  the  lesion, 
e.  g.,  acute  softening,  hydrocephalus  occurs  and  renders  the  irritation  of  the  central  gan- 
glia impossible  on  account  of  pressure;  or,  again,  the  pathological  change  {e.  g.,  new 
growth),  does  not  give  rise  to  symptoms  until  it  presses  mechanically  on  the  central 
ganglia. 

13.  The  most  essential  symptom,  in  uncomplicated  diseases  of  the  meninges  (Gehirn- 
wande),  is  convulsions;  and  paralysis  never  occurs  without  previous  convulsions. 

Here  Professor  Benedikt  enters  upon  the  signification  of  single 
symptoms  for  localizing  the  lesion,  and  states  that  psychical  disturb- 
ance, under  all  circumstances,  points  to  primary  or  secondary  disease 
of  the  convolutions  of  the  brain  : 

Static  vertigo  (Statisches  Schwindel,  lateral  progression)  shows  an  affection  of  the  cere- 
bellum, although  the  entrance  of  the  cerebellar  fibres  into  the  crura  cerebri  may  be  dis- 
eased. 

Contractions  of  central  origin  may  be  of  spinal  or  cerebral  nature ;  the  former  are, 
usually  bilateral,  the  latter  unilateral;  the  former  are,  as  a  rule,  limited  to  the  extensors 
the  latter  to  the  flexors.  Spinal  contractions  never  occur  without  evidence  of  abnormal 
reflex  irritability,  and  are  both  excited  and  increased  by  sensorial  influences ;  cerebral 
contractions  are  likewise  the  product  of  sensorial  irritation,  since  they  generally  cease 
during  sleep,  and  are  increased  by  every  sensorial  impression.  But  cold  and  heat  have 
also  influence  over  the  contractions  of  cerebral  origin.  Hence,  it  may  be  said,  contrac- 
tions are  probably  not  independent  motor  symptoms,  but  are  caused  by  sensible  and  sen- 
sorial reflex  action. 

Treinbling,  caused  by  the  rhythmical  contraction  of  groups  of  antagonistic  muscles,  may 
be  either  of  spinal  or  of  cerebral  origin.  It  is  not  identical  with  paralysis  agitaus,  the 
latter  being  a  morbid  unit. 

14.  Trembling,  as  a  symptom,  cannot  be  referred  to  any  special  location  of  the  lesion. 

15.  Influence  of  sensorial  irritation  upon  a  phenomenon  due  to  motor  irritation  is  no 
proof  of  location  of  lesion  within  the  brain,  considering  that  the  morbid  phenomena  in 
locomotor  ataxia  are  notoriously  caused  by  disease  of  the  sensitive  part  of  the  cord,  and 
that  choreic  spasms  depend  on  sensorial  and  probably  also  on  increased  spinal  irritability; 
further,  that  convulsions  symptomatic  of  brain  disease  are  observed  only  in  a  condition 
of  irritability  of  the  hemispheres  ;  it  follows  : 

16.  Phenomena  of  motor  irritation  from  central  cause  are  excited  especially  by  the 
irritation  or  at  least  the  co -operation  of  the  sensitive  and  the  sensorial  fibres.  But  even 
when  all  the  chasms  in  the  localization  of  all  symptoms,  and  of  the  groups  of  symptoms 
caused  by  foci  of  disease,  are  filled  up,  there  still  remains  a  large  number  of  cases  in  which 
an  attempt  at  exact  localization  must  fail.  This  is  owing  to  the  fact  that  many  forms  of 
disease  [e.  g.,  sclerosis,  hemorrhage,  many  new  formations,  etc.)  have  a  tendency  to  be- 
come diffused.  There  is  only  the  question  whether  there  is  reason  to  suspect  a  diffused 
process,  and  how  it  can  be  localized.  The  first  question  can  be  easily  answered.  There 
is  reason  to  suspect  a  diffused  process  when  the  symptoms  due  to  known  and  different 
localities  are  combined,  and  occur  together.  It  is,  then,  evident  that  the  concentration- 
law  of  Bell  (A.)  does  not  answer,  and  that  another  law,  the  diffusion-law  of  localization 
(B.)  must  be  employed. 


DEVELOPMENT    OF    THE   NERVOUS    SYSTEM    BY    EVOLUTION.  33 1 

B.  If  a  combination  of  symptoms  and  groups  of  symptoms  with  known  and  different 
localization  of  lesions  is  present,  each  must  be  referred  by  itself  to  its  known  locality. 
This  rule  is  so  simple  it  would  seem  needless  to  mention  it,  but  the  history  of  diffused 
sclerosis,  of  dementia  paralytica,  of  chorea  minor,  etc.,  shows  that  even  now  it  is  but  little 
regarded. 

This  translation,  from  the  German  of  Professor  Benedikt,  is  by 
the  able  pen  of  Dr.  Winslow,  of  London,  the  editor  of  the  London 
Journal  of  Psychological  Medicine  and  Mental  Pathology .  Respecting 
the  diagnosis  of  diseases  of,  or  injuries  to,  the  spinal  cord,  there  are 
some  excellent  rules  for  localizing  the  lesion  in  the  cord  by  Dr.  C.  E. 
Brown-Sequard,  which  I  insert : 

1st.  A  paralysis  of  voluntary  movements,  limited  to  one  of  the  lateral  halves  of  the  body, 
shows  that  the  lesion  is  in  the  corresponding  half  of  the  spinal  cord. 

2d.  A  paralysis  of  the  muscular  sense,  in  one  only  of  the  lateral  halves  of  the  body, 
shows  also  that  the  lesion  is  in  the  corresponding  half  of  the  spinal  cord. 

3d.  A  paralysis  of  the  vaso-motor  nerves  chiefly  evidenced  by  an  elevation  of  temper- 
ature in  one  of  the  lateral  halves  of  the  body,  equally  shows  that  the  lesion  is  in  the  cor- 
responding half  of  the  spinal  cord. 

4th.  Hypersesthesia — i.  e.,  an  increased  power  of  feeling  and  not  pain — in  one  of  the 
lateral  halves  of  the  body,  clearly  indicates  also  that  the  lesion  is  in  the  corresponding 
half  of  the  spinal  cord. 

5th.  The  various  ocular  and  facial  symptoms  which  we  know  as  effects  of  the  paraly- 
sis of  the  cervical  sympathetic  nerve — i.  <?.,  vascular  dilatation,  elevation  of  temperature, 
hyperaesthesia,  partial  closure  of  the  eyelids,  constriction  of  the  pupil,  etc. — in  one  of  the 
lateral  halves  of  the  head  and  face,  positively  show  also  that  the  lesion  is  in  the  correspond- 
ing half  of  the  spinal  cord. 

6th.  Anaesthesia  in  one  of  the  lateral  halves  of  the  body  leaves  no  doubt  that  the  lesion 
is  in  the  opposite  half  of  the  spinal  cord. 

Two  more  propositions  are  given,  relating  also  to  cases  in  which 
it  is  known  that  an  injury  or  a  disease  exists  in  the  spinal  cord : 

1st.  When  a  paralysis  exists  on  both  sides  of  the  body,  in  a  greater  degree,  however, 
in  one  than  in  the  other,  the  lesion  is  in  both  sides  of  the  spinal  cord,  but  chiefly  in  the 
side  corresponding  to  that  of  the  greater  degree  of  the  paralysis. 

2d.  When  a  complete  or  very  marked  anaesthesia  exists  in  one  of  the  lateral  halves  of 
the  body,  with  some  diminution  of  sensibility,  instead  of  hyperaesthesia,  in  the  other  half, 
the  lesion  exists  chiefly  in  the  lateral  half  of  the  spinal  cord  corresponding  to  the  side  of 
least  anesthesia,  but  it  extends  slightly  to  the  other  half  of  the  spinal  nervous  centre. 

These  rules  make  it  possible  to  make  a  very  exact  diagnosis  as  to 
the  seat  of  lesion,  in  diseases  of  or  injuries  to  the  spinal  cord,  where  the 
result  is  spinal  hemiplegia.  There  are  some  points  in  the  regional  di- 
agnosis of  brain  diseases  producing  paralysis  which  have  been  clearly 
delineated  by  Dr.  Charlton  Bastian,  of  London,  which  may  properly 


332  PSYCHOLOGICAL   MEDICINE. 

be  spoken  of  at  the  end  of  this  chapter.  If  we  have  large  lesions  in 
the  central  parts  of  the  pons  varolii,  we  find  in  our  patient  deep  apo- 
plectic symptoms,  characterized  by  deep  coma,  complete  paralysis 
of  limbs  on  both  sides,  flapping  of  the  cheeks  during  expiration,  in- 
sensibility of  conjunctiva,  and  very  much  contracted  pupils.  Death 
may  take  place  in  a  few  minutes,  a  few  hours,  or  in  a  day  or  two. 
Where  there  is  a  speedily  fatal  result  this  occurs  when  the  patient  is 
in  a  state  of  collapse,  with  a  temperature  lower  than  normal,  but 
where  life  is  prolonged  for  a  few  hours  the  temperature  steadily  rises, 
till  at  the  time  of  death  it  may  have  attained  109°  or  110°,  a  condi- 
tion of  profound  coma  continuing  all  the  time.  From  a  slight  lesion 
in  the  pons  consciousness  may  be  regained,  but  there  remains  a  gen- 
eralized paralysis,  more  or  less  equally  distributed  over  the  two  sides 
of  the  body.  Sensibility  may  be  diminished  or  perverted,  and  in  a 
lesion  involving  the  central  part  of  the  pons  varolii,  we  shall  find 
well-marked  but  irregular  paralysis  about  the  face,  involving  eyelids, 
mouth  and  tongue,  difficulty  in  deglutition,  and  well-marked  diffi- 
culty in  articulation. 

If  a  lesion  exists  in  the  loiver  half  of  one  lateral  region  of  the  pons 
varolii  we  get  "alternate  hemiplegia,"  in  which  we  find  a  very  well- 
marked  facial  paralysis  on  the  side  of  the  brain  lesion,  and  a  more 
or  less  complete  motor  and  sensory  paralysis  of  the  limbs  of  the  op- 
posite side.  Such  a  hemiplegia  may  set  in  with  apoplectic  symp- 
toms, or  there  may  be  an  epileptiform  mode  of  onset ;  while  in  other 
cases  it  supervenes  more  gradually,  without  either  loss  of  conscious- 
ness or  convulsions.  If  the  injury  or  disease  is  in  the  zipper  part  or 
half  of  one  lateral  region  we  get  the  same  kind  of  hemiplegia  I  have 
just  spoken  of,  but  with  the  well-marked  paralysis  of  the  face  exist- 
ing on  the  side  opposite  the  brain  lesion,  or  on  the  same  side  of  the 
body  as  the  paralysis  ;  for  here  the  fibres  of  the  facial  are  implicated 
above  their  point  of  decussation  in  the  pons,  just  as  the  motor  chan- 
nels for  the  limbs  are  implicated  above  their  decussation  in  the  me- 
dulla. The  facial  paralysis  is  so  well-marked  as  to  involve  the  or- 
bicularis palpebrarum,  and  there  are  difficulties  in  deglutition  and 
articulation  whichever  half  of  the  lateral  region  is  implicated.  The 
impairment  of  sensibility  is  variable  as  the  lesion  approaches  near  to 
or  actually  involves  the  ventricular  aspect  of  the  pons,  and  where  it 
exists  it  is  apt  to  be  more  marked  and  more  durable  than  in  the  great 
majority  of  cases  of  hemiplegia  due  to  lesions  further  away  from  the 
base  of  the  brain.     Sometimes  we  have  a  limited  unilateral  hyper- 


DEVELOPMENT    OF   THE   NERVOUS    SYSTEM    BY    EVOLUTION.  333 

aesthesia  instead  of  anaesthesia.  There  is  apt  to  be  marked  emotional 
disturbance  in  these  lesions  of  the  pons,  the  patient  having  great 
tendency  to  laugh  or  cry.  When  lesions  of  the  pons  cause  irritation 
of  parts  of  the  surface  of  the  floor  of  the  fourth  ventricle,  we  may 
find  sugar  in  the  urine ;  polyuria  or  albuminuria  if  lower  portions  of 
the  fourth  ventricle  are  implicated.  Slight  lesions  of  the  pons  are 
frequently  ushered  in  by  an  epileptiform  attack  without  loss  of  con- 
sciousness or  convulsions.  Early  rigidity  is  met  with  in  lesion  of  the 
pons,  and  there  may  be  rigidity  of  some  of  the  muscles  of  the  neck. 
When  lesions  occur  in  the  cms  cerebri,  the  diagnosis  may  be  easy 
or  extremely  difficult,  depending  upon  the  situation  and  extent  of  the 
lesion.  If  the  inner  and  hifenor  part  of  the  crus  near  the  pons 
be  injured,  or  if  there  should  be  a  large  lesion  implicating  this  and 
contiguous  parts  of  the  crus,  the  third  nerve  on  the  same  side  be- 
comes paralyzed,  whilst  a  hemiplegic  condition  is  also  established  in 
the  opposite  half  of  the  body.  If,  on  the  contrary,  the  lesion  impli- 
cates only  the  upper  and  outer  part  of  the  crus — the  part  next  the 
cerebral  hemisphere — the  diagnosis  is  then  very  difficult,  there  being 
no  distinctive  sign  of  a  lesion  in  this  situation,  and  the  grouping  of 
symptoms  approximates  very  closely  to  that  met  with  in  lesions  of 
the  optic  thalamus.  When  the  lesion  is  in  the  lower  and  inner  part 
of  the  crus  we  get  an  "  alternate  paralysis,"  the  third  nerve  being 
paralyzed  on  the  side  of  the  brain  lesion,  shown  by  ptosis  or  drop- 
ping of  the  eyelid  on  the  same  side,  by  dilatation  and  sluggish- 
ness of  the  pupil,  by  external  squint  causing  double  vision,  and  by 
its  being  impossible  for  the  patient  to  move  his  eyeball  except  slightly 
further  outwards  owing  to  forced  contraction  of  the  external  rectus, 
and  a  little  around  its  own  axis  in  one  direction — from  outwards, 
upwards ;  owing  to  forced  contraction  of  the  superior  oblique  mus- 
cle. All  the  muscles,  then,  of  the  eyeball  are  paralyzed,  except  the 
external  rectus  and  the  superior  oblique,  which  are  supplied  by  the 
sixth  and  fourth  nerves  respectively.  The  hemiplegia,  on  the  oppo- 
site side  of  the  body,  is  very  like  that  produced  by  a  lesion  in  the 
upper  part  of  one  lateral  half  of  the  pons  varolii ;  the  tongue  gener- 
ally deviating  distinctly  to  the  paralyzed  side,  and  the  facial  paralysis 
about  the  mouth  being  well-marked.  The  articulation  is  often  af- 
fected, or  there  may  be  only  a  slight  thickness  of  speech  for  a  short 
time.  Deglutition  may  not  be  interfered  with.  Sensibility  is  gen- 
erally much  impaired  on  the  paralyzed  side,  the  impairment  lasting 
some  time,  and  being  most  marked  in  the  limbs.     The  temperature 


334  PSYCHOLOGICAL    MEDICINE. 

of  the  paralyzed  side  may  be  as  much  as  two  degrees  higher  than 
that  of  the  non-paralyzed  side. 

The  motor  paralysis  occasioned  by  lesions  in  or  about  the  optic 
thalamus,  are  not  so  pronounced  as  that  produced  by  lesion  in  or 
about  the  corpus  striatum,  and  sometimes  even  may  be  entirely  want- 
ing. Early  tonic  and  clonic  spasms  in  the  paralyzed  limbs  or  about 
the  face  and  neck,  are  especially  frequent  in  lesions  of  the  optic  thal- 
amus. Sensibility  is  about  equally  impaired  in  lesions  of  the  optic 
thalamus  and  corpus  striatum.  There  is  a  greater  difference  in  tem- 
perature in  lesions  of  the  optic  thalamus  than  when  the  lesion  is  in 
the  corpus  striatum  ;  in  the  latter  the  temperature  rarely  being  more 
than  one  degree  higher  thanthatof  the  limbs  of  the  sound  side,  while 
in  the  former  case  the  difference  may  be  one  and  a  half  to  two  de- 
grees, and  may  persist  for  a  much  longer  time,  perhaps  for  many 
weeks. 

The  aphasic  difficulties  met  with  when  the  lesion  is  in  or  just  out- 
side of  the  left  corpus  striatum,  are  not  generally  met  with  when  similar 
lesions  occur  about  the  left  thalamus.  If,  however,  the  two  bodies 
are  damaged  at  the  same  time,  we  shall  then  find  the  aphasic  trou- 
bles and  early  rigidity  and  other  symptoms  more  indicative  of  a 
lesion  in  the  thalamus.  When  there  is  haemorrhage  into  the  corpus 
striatum  or  thalamus,  followed  by  effusion  into  the  ventricles,  we  may 
at  first  find  our  patient  with  an  ordinary  hemiplegia,  which  has  com- 
menced by  an  apoplectic,  or  epileptiform,  or  simple  form  of  onset, 
and  after  a  short  interval  a  new  haemorrhage  may  occur,  the  blood 
tearing  its  way  into  the  lateral  ventricles,  so  that  profound  coma, 
stertor  and  general  paralysis  quickly  come  on.  In  other  cases, 
without  any  preliminary  attack,  a  large  haemorrhage  may  take  place, 
and  the  blood  pouring  into  the  lateral  ventricles,  we  have  at  once  a 
marked  apoplectic  attack,  characterized  by  deep  coma,  general  pa- 
ralysis of  limbs,  and  dilated  pupils.  The  temperature  is  decidedly 
lowered  in  all  these  cases,  sinking  to,  perhaps,  96°,  followed  in  an 
hour  or  two — if  a  fatal  result  does  not  .speedily  occur — by  a  rapid 
rise,  which  slowly  continues  in  cases  about  to  prove  fatal,  till  the 
death  of  the  patient.  Such  a  fatal  ending  often  occurs  within  three 
days  from  the  commencement  of  the  attack. 

When  the  haemorrhage  affects  the  ventricles  we  often  see  tonic 
spasms  of  some  of  the  limbs,  or,  tonic  may  alternate  with  clonic 
spasms  of  the  same  parts.  In  some  cases  we  may  find  rigidity  of 
the  limbs  of  one  side  combined  with  clonic  spasms  in  one  or  both 


DEVELOPMENT    OF    THE    NERVOUS    SYSTEM    BY    EVOLUTION.  335 

extremities  of  the  opposite  side.  We  may  also  see  in  this  class  of 
cases,  a  conjugated  deviation  of  the  eyes,  sometimes  present  from 
the  first,  pointing  to  the  side  of  the  brain  on  which  the  haemorrhage 
with  laceration  has  occurred.  If  the  coma  is  not  too  profound,  we 
may  discover  some  slight  signs  of  sensibility  on  the  side  of  the 
body  towards  which  the  eyes  are  turned.  From  the  above-men- 
tioned symptoms  we  may  safely  diagnose  (in  the  majority  of  cases)  a 
haemorrhage  into  the  lateral  ventricles,  although  sometimes  there 
maybe  from  a  lesion  in  the  pons,  a  combination  of  symptoms  closely 
imitating  those  I  have  detailed. 

In  the  class  of  cases,  however,  where  the  lesion  in  the  pons  is 
small  at  first  and  gradually  increasing,  the  hemiplegia  is  generally 
of  such  a  nature  as  to  make  it  referable  to  a  lesion  of  the  pons,  and 
when  the  lesion  in  the  pons  varolii  is  large  from  the  first,  the  con- 
dition of  coma  and  general  paralysis  is  apt  to  be  associated  with 
contracted  and  motionless  pupils,  as  in  opium  poisoning,  whereas, 
in  haemorrhage  into  the  ventricles,  the  pupils  are  generally  dilated. 
Tonic  spasms  are  more  frequently  absent  in  severe  central  lesions  of 
the  pons,  than  in  cases  where  the  haemorrhages  occur  into  the  ven- 
tricles. 

There  are  instances  where  the  symptoms  of  secondary  haemor- 
rhage into  the  ventricles  are  closely  simulated;  where  a  hemiplegia 
condition  from  injury  to  the  opposite  side  of  the  brain  becomes  com- 
plicated by  a  fresh  lesion  (either  softening  or  haemorrhage)  in  the 
previously  souiid  hemisphere. 

When  we  have  a  lesion  in  the  anterior,  middle  and  posterior  parts 
of  the  cerebral  hemispheres,  the  rule  is,  to  which  there  are  only  a  few 
exceptions,  that  a  lesion  in  either  hemisphere  of  the  brain,  if  of  suffi- 
cient extent,  induces  a  paralysis  of  the  limbs  of  the  opposite  side  of 
the  body.  Our  power  to  discriminate  during  life  between  lesions  oc- 
cupying different  situations  in  the  cerebral  hemispheres,  is  constantly 
increasing,  owing  to  the  able  work  done  by  our  American  neurolo- 
gists and  those  of  Europe. 

In  our  own  country  the  labors  and  brilliant  investigations  of  Drs. 
Hammond,  Seguin,  Putnam,  Eads,  Mills,  Morton,  Bartholow,  Webber, 
Amidon,  Bannister,  Jewell,  Hughes,  Hamilton,  Spitzka  and  others, 
have  done  a  great  deal  towards  the  solution  of  the  more  difficult 
problems  in  cerebral  diagnosis,  and  this  knowledge  will  be  constantly 
increasing. 

If  we  have  haemorrhage  in  the  anterior  lobe  or  softening  of  the 


336  PSYCHOLOGICAL    MEDICINE. 

same  part  caused  by  embolism  or  thrombosis  of  the  anterior  cerebral 
artery,  we  may  have  imphcations  of  the  olfactory  bulb,  or  interfer- 
ence with  its  functional  activity  by  the  pressure  on  the  part  of  the 
brain  where  it  is  situated,  so  that  we  may  have  loss  of  smell,  or  im- 
pairment of  this  sense  on  the  side  of  the  body  on  which  the  brain 
lesion  occurs,  and  opposite  to  the  side  of  the  paralysis  of  the  limbs. 
Lesions  of  the  posterior  part  of  the  left  frontal  convolution,  where 
we  have  a  right  hemiplegia,  are  often  associated  with  the  existence 
of  a  typical  aphasia. 

Almost  the  only  sign  of  a  lesion  of  softening  of  the  posterior  or 
occipital  lobe  of  the  brain,  is  the  loss  of  sight  in  the  eye  of  the  op- 
posite side,  as  well  as  paralysis  of  the  opposite  limbs.  The  unilateral 
loss  of  sight  and  the  hemiplegia  both  become  established  simulta- 
neously. In  case  of  softening,  this  results  from  occlusion  of  the  pos- 
terior cerebral  artery.  We  get  a  great  deal  of  cephalalgia  when  the 
meninges  are  markedly  affected.  We  may  get  more  or  less  pro- 
longed loss  of  consciousness  as  the  beginning  of  superficial  affections 
of  the  brain,  and  delirium  as  one  of  the  initial  symptoms.  We  may 
have  convulsions  ushering  in  acute  affections  of  the  cortical  gray 
matter  and  limited  tonic  and  clonic  spasms,  without  loss  of  conscious- 
ness, and  in  new  growths  involving  the  cortex,  convulsive  attacks 
may  occur  with  great  frequency.  We  may  get,  in  cortical  affections 
of  the  brain,  no  definite  paralysis  perhaps,  but  there  will  be  exhib- 
ited by  the  patient  great  general  weakness,  with  a  slow  vacillating 
mode  of  walking,  or  actual  inability  to  stand,  or  we  may  have  a  par- 
tial hemiplegia,  more  or  less  complete  paralysis  of  one  arm,  with 
slight  lowering  of  the  angle  of  the  mouth  on  the  same  side,  but  no 
appreciable  weakening  of  the  leg.  If  the  lesion  is  in  the  third  left 
frontal  convolution  or  adjacent  parts,  we  shall  get  aphasia,  either 
alone  or  in  association  with  the  partial  hemiplegia.  If  the  gray  mat- 
ter in  other  parts  is  met  with,  speech  may  be  affected  and  there  may 
be  well-marked  amnesia,  or  a  slow  and  labored  utterance,  merely 
with,  perhaps,  some  mental  incoherence.  The  loss  of  sensibility  in 
case  of  hemiplegia  due  to  superficial  lesions,  is  generally  very  slight, 
perhaps  scarcely  appreciable  at  all,  even  Avithin  a  few  days  from  the 
occurrence  of  the  trouble.  The  difference  in  temperature  in  these 
cases  is  also  very  slight  between  the  paralyzed  and  non-paralyzed 
side  of  the  body.  We  may  even  get  hypersesthesia  in  place  of  any 
anaesthesia  of  the  paralyzed  limbs.  We  must  look  at  the  symptoms 
collectively,  not  singly,  and  in  these   cases — lesions    limited   to   the 


DEVELOPMENT    OF   THE   NERVOUS    SYSTEM    BY    EVOLUTION.  337 

cortical  gray  matter  or  causing  pressure  upon  this  substance — we 
should  look  for  mental  incoherence  or  delirium,  a  partial  hemiplegia, 
a  little  affection  of  the  leg  or  face,  muscular  twitchings  in  the  limbs, 
absence  or  distinct  loss  of  sensibility,  or  of  any  notable  elevation  of 
temperature  on  the  paralyzed  side,  our  regional  diagnosis  of  a  lesion 
of  the  surface  of  the  brain  ought  to  be  readily  made. 

If  we  have  more  severe  superficial  lesions,  such  as  widespread 
embolisms  or  copious  arachnoid  haemorrhages,  we  shall  get  a  pro- 
found apoplectic  condition,  during  which  our  patient  may  die  with- 
out our  being  able  to  make  an  accurate  differential  diagnosis  of  the 
seat  of  the  lesion. 

With  respect  to  lesions  of  the  cerebellum,— a  difficult  region  for  ex- 
act diagnosis, — we  must  remember  that,  owing  to  the  intimate  func- 
tional relationship  existing  between  the  cerebrum  and  the  cerebellum, 
the  latter  acts  in  response  to  cerebral  stimuli,  plays  a  subordinate  part, 
although  injuries  or  lesions  of  the  cerebellum  may  seriously  irritate 
the  pons  and  medulla  oblongata,  or,  through  the  fibres  of  the  supe- 
rior cerebellar  peduncles,  may  seriously  disturb  the  cerebral  hemi- 
spheres. It  is  consequently,  as  I  have  said,  very  difficult  to  say 
which  of  the  symptoms  met  with  in  any  given  case  are  referable 
directly  to  destruction  or  irritation  of  the  cerebellar  substance,  and 
which  to  secondary  or  indirect  effects  of  these  injuries,  or  if  the  lesion 
which  caused  them  is  upon  adjacent  and  related  parts.  As  a  rule,  we 
may  probably  safel)^  say  that  all  direct  effects  resulting  from  lesions 
in  one  lateral  lobe  of  the  cerebellum  will,  so  far  as  they  are  con- 
nected with  motility,  show  themselves  principally  upon  the  side  of 
the  body  corresponding  with  the  lesion.  The  functional  relations  of 
the  cerebellum  are  chiefly  with  the  half  of  the  cord  and  the  limbs  on 
the  corresponding  side  of  the  body.  If  we  have  haemorrhage  or 
occlusion  of  the  vessels,  leading  to  softening  of  some  part  of  the  cere- 
bellum, we  shall  get  certain  symptoms  as  the  result  of  these  lesions. 
If  they  occur  in  the  lateral  lobe  of  the  cerebellum  we  shall  get  loss 
of  consciousness  or  not,  as  the  lesions  are  sudden  and  extensive  qr 
not.  Pain  of  a  severe  nature  may  be  referred  to  the  occipital  or 
frontal  region,  and  is  generally  paroxysmal,  and  vomiting  is  very 
frequent.  Paralysis  of  the  opposite  arm  and  leg  may  be  met  with 
without  much  diminution  of  sensibility.  This  paralysis  will  be  more 
marked  in  the  leg  than  in  the  arm,  and  will  probably  be  absent  from 
the  face.  It  is  different,  therefore,  in  both  these  respects,  from  the 
common  forms  of  hemiplegia,  and  differing  also  from  the  paralysis 


338  PSYCHOLOGICAL   MEDICINE. 

produced  by  superficial  lesions  of  the  hemispheres,  where,  though 
paralysis  of  the  face  may  be  absent,  the  loss  of  power  falls  more  upon 
the  arm  than  the  leg.  There  may  be  early  rigidity  in  the  paralyzed 
limbs,  spasms  about  the  face,  or  rigidity  of  the  neck.  Speech  is  not 
affected  and  the  tongue  is  not  interfered  with  in  its  movements. 
Deglutition,  as  a  rule,  is  not  interfered  with  generally,  although  if 
there  is  well-marked  pressure  on  the  medulla  we  may  find  dysphagia 
and  difficulty  in  articulation.  As  the  superior  peduncles  are  in  close 
proximity  to  the  corpora  quadrigemina  blindness  may  come  on  if 
they  are  affected.  We  should  expect  no  delirium  or  mental  disor- 
der, but  perhaps  we  may  find  intellectual  torpor  and  drowsiness. 
Pulse  and  respiration  are  generally  good.  At  times  we  may,  from  a 
lesion  in  the  lateral  lobe  of  the  cerebellum,  have  no  hemiplegia,  but 
only  a  general  muscular  weakness  of  a  progressive  nature,  more 
marked  in  the  legs  than  in  the  arms.  Sometimes  this  prostration  is 
so  great  that  the  patient  cannot  stand  or  even  raise  himself  in  bed. 

If  the  lesion  is  in  the  median  lobe  of  the  cerebellum  we  have 
variance  in  the  symptoms  according  to  the  extent  and  suddenness, 
and  the  variable  amount  of  pressure  upon  the  medulla  and  pons.  If, 
for  instance,  we  had  a  large  haemorrhage  in  this  situation,  causing 
pressure  on  the  medulla  and  pons,  we  may  have  sudden  and  well- 
marked  apoplectic  symptoms,  terminating  fatally  in  a  short  time.  Gen- 
erally the  lesions  are  not  so  severe  as  this  in  this  locality.  Hemiplegia 
would  be  more  likely  to  be  absent  than  if  the  lesion  were  in  the 
lateral  lobes  of  the  cerebellum.  We  may  have  marked  excitation  of 
the  genital  functions  where  the  lesion  is  in  the  median  lobe.  In  both 
sexes  sexual  desire  is  increased,  and  in  male  patients  there  are  fre- 
quent erections,  with  or  without  emissions.  We  do  not  get  these 
symptoms  where  only  the  lateral  lobes  of  the  cerebellum  are  affected. 
Sight  will  be  affected  if  there  is  a  large  lesion  in  the  middle  lobe, 
owing  to  the  proximity  of  the  superior  cerebellar  peduncles,  which 
are  in  such  close  topographical  relation  with  the  corpora  quadri- 
gemina. Tumors  are  more  likely  than  haemorrhage  to  lead  to  ven- 
tricular dropsy  or  central  softening  in  this  situation,  by  causing  im- 
pediment of  return  of  blood  from  the  veins  of  Galen  into  the  straight 
sinus,  and  here  the  symptoms  of  cerebellar  disease  may  be  indefinite, 
owing  to  the  symptoms  induced  by  the  ventricular  dropsy  and  innu- 
trition of  the  central  regions  of  the  brain. 

To  discover  the  nature  of  the  lesion  which  has  occurred  in  brain- 
tissue   is   oftentimes  very  difficult.     For  instance,  the   question  of 


DEVELOPMENT    OF   THE    NERVOUS    SYSTEM    BY    EVOLUTION.  339 

the  differential  diagnosis  between  haemorrhage  and  softening.     We 
have  to    look    at   the    age    and    general   health   of  the   patient,  at 
the  condition  of  his  heart  and  larger  arteries,  at  the  presence   or 
absence  of  prodromata,  at  the  actual  mode  of  onset  of  the   disease, 
and  at  its  progress  as  regards  general  symptoms  during  the  first  few- 
days.     In  making  our  pathological  diagnosis  as  to  the  causes  that 
have  given  rise  to  the  apoplectic  condition  in  a  given  case,  we  must 
determine  whether  our  patient,  if  he  has  been  found  in  a  comatose 
condition,  has  suffered   from  any  external  violence  causing  internal 
injury,  from  narcotic  poisoning;  whether  he  is  suffering  from  intoxi- 
cation, from  ursemic  coma;  whether  he  is  in  the  stupor  following  an 
epileptic  fit;  or  finally,  whether  the  patient  has  actual  cerebral  disease 
from  rupture  or  occlusion  of  the  cerebral  bloodvessels.     In  distin- 
guishing between   opium   poisoning  and  haemorrhage  into  the  pons 
varolii  in  its  central  part,  while  in  both  cases  there  is  profound  coma 
and  pin-head  contraction  of  the  pupils,  in  the  former  case  the  coma 
comes  on  slowly,  while  in  the  latter  the  coma  comes  on  rapidly.     In 
uremic  coma  our  patient  will  present  a  pale,  pasty  complexion,  puffy 
eyelids,  swollen  ankles,  and  albuminous  urine,  and  convulsions  would 
commence  the  attack  which  drowsiness  and  headache  have  markedly 
ushered  in,  and  the  temperature  of  the  body  begins  to  fall  with  the 
commencement  of  the  ursemic  coma,  continuing  to  sink  as  long  as 
this  condition  lasts,  sinking,  in  fatal  cases,  as  low  as  90°  F.,  while  in 
cerebral  haemorrhage  or  softening,  the  lowering  of  temperature  is 
slighter,  and  if  the  haemorrhage  is  not  fatal  in  two  or  three  hours, 
rarely  lasts  longer  than  this. 

If  a  young  person  whom  we  knew  to  be  affected  with  valvular 
disease,  suddenly  became  hemiplegic,  we  could  at  once  safely  diag- 
nose cerebral  embolism.  Embolism  generally  occurs  in  persons 
under  forty  years  of  age,  while  cerebral  haemorrhage  generally 
occurs  after  this  age  ;  thrombosis  and  haemorrhage  have  the  great- 
est tendency  to  occur  in  old  people.  Long  or  well-marked  prodro- 
mata, terminating  with  an  attack  of  hemiplegia  in  elderly  persons, 
especially  if  their  heart  is  weak  and  the  arteries  rigid,  would  in- 
cline us  to  make  a  diagnosis  of  thrombosis. 

The  indications  pointing  toward  haemorrhage  as  a  lesion  would  be 
a  profound  and  lasting  coma  from  which  the  patient  cannot  be  roused, 
especially  when  the  attack  has  not  been  ushered  in  by  convulsions. 
Sudden  haemorrhage  into  the  pons  varolii,  a  large  haemorrhage  into 
the  lateral  ventricles  or  into  the  arachnoid  sac,  would  give  rise  to 


340  PSYCHOLOGICAL    MEDICINE. 

such  symptoms,  which  may  speedily  terminate  in  death.  Multiple 
embolisms  occurring  simultaneously  over  a  large  tract  of  the  brain, 
might,  however,  give  us  the  same  symptoms  and  a  similarly  speedy 
death,  as  when  a  large  atheromatous  collection  near  the  aorta  is  sud- 
denly liberated  and  carried  into  the  circulation,  so  that  considerable 
of  it  is  carried  to  the  brain,  simultaneously  blocking  up  a  large  num- 
ber of  small  vessels.  This,  however,  would  be  a  rare  occurrence. 
A  sudden  and  profound  coma  might  be  produced — although  it,  also, 
would  be  a  rare  occurrence — by  a  thrombus  completely  occluding 
the  basilar  artery  in  nearly  its  whole  length.  The  onset  in  these 
cases  would  be  apt  to  be  more  gradual. 

In  cases  of  softening  due  to  thrombosis  the  symptoms  go  on  in- 
creasing by  successive  stages  for  a  week  or  so,  and  in  softening  due 
to  embolism  there  is  very  apt  to  be  a  remission  and  diminution  of 
the  paralysis  three  or  four  days  after  the  beginning  of  the  attack. 
It  is  sometimes  very  difficult,  in  cases  where  a  hemiplegic  attack 
begins  with  either  a  slightly-marked  apoplectic  condition  or  with  no 
loss  of  consciousness  at  all,  to  diagnose  with  certainty  between  haem- 
orrhage and  softening,  except  as  we  know  in  some  cases  that  embo- 
lism has  occurred,  and  in  another  set  of  cases  where  long-continued 
prodromata  point  to  thrombosis.  We  have  to  watch  the  subsequent 
course  of  the  illness  for  the  first  week.  In  haemorrhage  there  is  apt 
to  be  a  febrile  reaction  after  three  or  four  days,  leading  to  exaggera- 
tion of  the  symptoms,  or  there  may  be  an  increase  in  the  severity  of 
the  symptoms,  taking  place  by  successive  stages,  particularly  when 
slight  additional  bleedings  occur' at  corresponding  intervals,  and 
these  cases  very  closely  simulate  cases  of  softening  by  thrombosis. 
The  period  of  initial  lowering  of  the  temperature  met  with  generally 
in  haemorrhage  is  either  absent  or  very  much  less  marked  in  cere- 
bral softening. 

In  cerebral  haemorrhage,  if  the  temperature  rises  soon  after  the 
attack  to  102°  or  103°,  it  very  rarely  sinks  again  unless  from  the 
shock  of  a  new  hemorrhage,  while  in  softening  there  may  be  a  rise 
to  102°  or  104°,  followed  by  a  sudden  fall  and  subsequent  oscilla- 
tions. In  children  haemorrhages  are  generally  arachnoid,  as  they 
are  also  after  blows  on  the  head  if  haemorrhage  comes  on.  * 

*  A  weakened  vascular  wall  and  increased  pressure  within  the  vessel  are  the  general 
cause  of  cerebral  hemorrhage.  It  is  rare  dui-ing  the  first  half  of  life,  and  generally 
occurs  after  fifty  years  of  age.  Chronic  Bright's  disease  and  chronic  alcoholism,  also 
chloral   and  opium  habits,  lead  to  degeneration  of  vessels,  and  are  thus  predisposing 


DEVELOPMENT    OF    THE    NERVOUS    SYSTEM    BY   EVOLUTION.  34 1 

Haemorrhage  is  more  apt  than  softening  to  occur  in  the  middle 
lobes  of  the  cerebellum,  and  signs  of  disease  in  the  optic  thalamus 
are  more  apt  to  be  caused  by  haemorrhage  than  by  softening. 

Our  prognosis  in  cases  of  cerebral  haemorrhage  will  depend  upon 
the  age  and  state  of  health  of  the  patient,  taken  in  connection  with  our 
view  of  the  situation  of  the  lesion,  its  pathological  nature,  and  its  ex- 
tent. The  friends  will  wish  to  know  our  opinion  as  to  the  probabili- 
ties of  the  attack  itself  being  fatal,  or  what  are  the  chances  for  recov- 
ery of  speech  and  mental  power,  and  whether  power  will  be  regained 
in  the  paralyzed  limbs,  and  also  as  to  the  chances  of  a  repetition  of 
the  attack.  As  to  the  first  question,  as  to  the  attack  itself  immedi- 
ately proving  fatal,  we  must  be  guided  in  our  answer  by  the  exist- 
ing degree  of  coma.  If  our  patient  cannot  be  roused  at  all,  if  there 
is  no  reflex  action  when  the  conjunctivae  are  touched,  if  there  is  well- 
marked  stertor  with  involuntary  passages  of  urine  and  faeces,  the 
patient  may  die  rapidly  in  a  very  few  hours ;  and  in  cases  where 
death  does  not  immediately  ensue  or  recovery  takes  place,  the  per- 
sistence of  such  signs  without  abatement  for  twenty-four  hours  is  a 
grave  indication,  and  the  patient  will  probably  die  in  a  day  or  two. 

It  is  a  bad  symptom  if  the  respiration  is  very  slow  and  labored,  or .. 
if  it  is  quick,  with  marked  irregularity  of  pulse.  A  very  marked  and 
persistent  depression  of  temperature,  commencing  with  the  attack,  is 
a  sign  also  of  fatal  issue  of  the  case.  These  speedily  fatal  cases  are 
occasioned  by  haemorrhages  into  the  centrum  ovale,  with  or  without 
rupture  into  the  ventricles,  by  large  bleedings  on  the  surface  of  the 
brain  or  by  haemorrhage  into  the  pons  varolii.  Very  rarely  multiple  ' 
embolisms  of  the  brain  or  complete  thrombosis  of  the  basilar  artery 
may  produce  like  results. 

If  the  patient  gets  through  the  first  few  days  after  an  attack  of 
cerebral  haemorrhage,  the  result  will  then  be  influenced  by  his  gen- 
causes.  Nearly  half  the  intra-cerebral  haemorrhages  are  located  in  the  corpus  striatum 
and  the  region  just  outside  it.  The  pons  and  peduncles,  the  cerebellum,  the  cortex,  the 
optic  thalamus,  the  posterior  and  anterior  portion  of  the  hemisphere,  are  also  the  seats 
of  cerebral  hsemorrhage,  about  in  the  order  I  have  given  them.  An  elderly  person  may 
complain  of  headache,  vertigo,  slight  mental  disturbance,  and  slight  impairment  of 
speech  as  prodromata  of  an  attack  of  haemorrhage  into  the  brain.  It  must  be  remembered 
that  the  loss  of  consciousness  and  of  power  of  motion  and  sensation  are  profound  and 
lasting  according  to  the  size  and  location  of  the  hsemorrhage,  and  that  our  prognosis  is 
mainly  guided  by  the  intensity  of  the  symptoms  and  the  location  of  the  lesion.  A  com- 
bination of  hypophosphite  of  soda  and  the  tincture  of  nux  vomica,  as  recommended  by  Mr. 
Gowers,  of  England,  I  have  been  much  pleased  with  as  a  nervine  tonic,  after  cerebral 
hsemorrhage. 


342  PSYCHOLOGICAL   MEDICINE. 

eral  condition  and  the  state  of  the  other  organs  of  the  body,  so  that 
a  healthy  state  of  hver  and  kidneys,  and  good  general  nutrition  may 
be  the  means  of  warding  off  a  fatal  termination,  which  would  occur 
in  a  less  healthy  individual.  Sudden  rise  of  temperature  to  102°  or 
104°,  or  acute  sloughing  of  the  nates  within  a  few  days  after  the  on- 
set of  an  apoplectic  attack,  are  grave  indications.  Great  difficulty  in 
deglutition  is  always  a  grave  symptom,  since,  if  it  is  well-marked,  we 
generally  have  to  do  with  lesions  near  the  medulla ;  and  severe  emo- 
tional weakness  is  another  bad  symptom.  Sudden  depression  of 
temperature,  with  increase  or  renewal  of  comatose  condition,  is  in- 
dicative of  fresh  haemorrhage,  although  we  may  get  these  symptoms 
in  cases  of  softening  from  new  and  sudden  occlusions. 

If  our  patient  goes  through  the  first  twelve  days,  we  do  not  look 
for  a  fatal  result  from  the  brain  lesion  or  from  its  corhplications. 

He  will  now,  probably,  slowly  regain  his  power  of  easy  deglutition 
and  speaking,  and  his  mental  power,  his  mental  weakness  displaying 
itself  merely  in  an  increased  tendency  to  emotional  display.  He  is 
easily  worried  and  has  less  self-control,  and  the  memoiy  is  somewhat 
weakened.  Rarely,  there  may  be  a  mental  impairment  produced 
which  will  end  in  dementia,  more  especially  in  elderly  people,  or 
when  the  lesions  affect  the  cortex  of  the  brain.  In  children,  in  in- 
fancy or  at  birth,  large  lesions  in  the  substance  or  on  the  surface  of 
the  brain  may  produce  idiocy  and  tendency  to  convulsions.  Re- 
specting the  return  of  motor  power  to  the  paralyzed  limbs,  slight 
power  ought  certainly  to  be  regained  in  three  or  four  weeks,  and  if  it 
is  not,  the  prognosis  in  this  respect  is  bad.  The  later  the  first  signs 
of  returning  motility  are  in  showing  themselves,  the  less  the  chance 
for  complete  recovery. 

Early  rigidity,  especially  in  the  upper  extremities,  is  unfavorable,  as 
the  limbs  are  apt  not  to  recover  their  motor  power,  but  to  pass  into 
late  rigidity  with  organic  change  in  nerves,  muscles,  and  joints. 
This  is  one  of  the  rarer  occurrences  in  the  hemiplegic  state.  In  a 
great  many  cases  patients  will  make  a  good  recovery  from  an  attack 
of  cerebral  haemorrhage,  recovering  from  the  apoplectic  condition  and 
regaining  power  over  the  paralyzed  limbs,  and  the  more  quickly 
motor  power  manifests  itself  in  the  limbs  the  more  likelihood  of  its 
being  complete.  A  recurrence  of  the  paralysis  is  most  likely  in  per- 
sons over  sixty  years  of  age,  who  are  affected  by  arterial  degeneration. 
In  younger  persons  with  endocardial  vegetation  an  attack  of  embo- 
lism may  be  repeated  at  any  time  from  sudden  emotion  or  violent 


DEVELOPMENT    OF   THE   NERVOUS    SYSTEM    BY   EVOLUTION.  343 

exercise,  which  may  so  quicken  the  heart's  action  as  to  wash  off  an 
embolic  fragment,  which  may  block  up  one  of  the  middle  cerebral 
arteries. 

In  treating  these  cases  we  have  no  specifics,  but  must  rely  on  the 
natural  process,  and  nature  will  often  effect  a  cure  if  not  interfered 
with.  It  often  requires  the  highest  wisdom  to  abstain  from  inter- 
fering too  actively  with  the  reparation  nature  sets  up  to  absorb  a 
clot  of  blood  in  the  brain.  If  we  are  trying  to  avert  a  threatened 
cerebral  hsemorrhage,  we  must  insist  on  absolute  rest  of  mind  and 
body,  keep  the  patient  cool,  keep  the  head  and  shoulders  well  raised, 
give  milk  diet,  and  keep  the  heart's  action  quiet  by  bromide  of  sodium, 
and  in  treating  the  actually  developed  apoplectic  condition  we  must 
treat  our  patient  in  a  large  cool  room,  with  ice-bags  to  the  head,  and 
keep  the  head  and  shoulders  well  raised,  and  keep  hot  bottles  at  the 
feet.  The  bromides  and  aconite  and  veratrum  viride  may  be  used  pro 
re  nata  to  moderate  excessive  force  of  the  heart's  action,  and  we  must 
stimulate  if  the  respiration  is  slow  and  the  pulse  weak.  The  bowels 
may  be  unloaded  by  enemata,  and  the  bladder  carefully  attended  to. 
Quiet,  rest,  and  a  cheerful  nurse  are  essential  to  recovery.  Passive 
movement,  frictions,  the  induced  current  of  electricity  (not  in  an  early 
stage,  however)  and  strychnia  in  ^'^-grain  doses  thrice  daily,  consti- 
tute the  principal  treatment  after  a  time.  The  phosphide  of  zinc  tV 
grain,  or  cod-liver  oil  and  phosphorus  may  be  given  with  advantage 
at  a  later  date,  and  also  the  chloro-phosphide  of  arsenic  (Routh's 
formula)  in  5 -minim  doses  gradually  decreased. 

We  must  look  after  our  patient's  general  health,  and  rouse  his  dor- 
mant nerves  and  muscles,  at  the  same  time  keeping  away  from  him 
everything  prejudicial  to  his  ultimate  recovery. 

Respecting  the  clinical  observation  of  diseases  of  the  brain  and 
nervous  system,  Dr.  Thomas  Laycock,  Professor  of  the  Practice  of 
Medicine,  of  Clinical  Medicine  and  of  Medical  Psychology  and  Men- 
tal Diseases,  in  the  University  of  Edinburgh,  speaks  as  follows  : 

The  law  of  direction  of  physiological  activity  or  of  the  vis  7iervosa,  applied  to  the  in- 
vestigation of  diseases  of  the  brain  and  nervous  system,  is  really  an  application  to  clin- 
ical research  of  the  well-knovsrn  laws  of  reflex  action.  But  very  few  are  aware  that 
the  direction  of  physiological  activity  indicates  also  the  direction  of  structural  degenera- 
tion. For  this  reason,  and  because  of  its  great  practical  importance,  I  must  call  your 
special  attention  to  this  general  fact.  As  the  late  Dr.  Waller  demonstrated  it  to  be  the 
law  of  degeneration  of  both  the  motor  and  sensory  spinal  nerves,  and  showed  its  value  as 
a  means  of  both  anatomical  and  pathological  research,  I  have  named  it  the  Wallerian 


344  PSYCHOLOGICAL    MEDICINE. 

Law.  I  am,  however,  responsible  for  extending  its  application  from  the  spinal  cord 
and  nerves  to  the  brain  and  nerves  of  special  sense.  I  may  say  now  that,  on  the  report 
of  Claude  Bernard,  Dr.  Waller  was  awarded  the  prize  of  2000  francs,  given  by  the 
Academy  of  Sciences,  for  experimental  physiology  in  1856.  You  will  find  the  extended 
views  of  the  question  in  my  physiological  text-book.  The  facts  are  simple.  If  the  two 
roots  of  the  second  cervical  pair  of  nerves  of  an  animal  be  divided  (and  this  can  be  done 
in  the  dog  and  cat  without  exposing  the  cord),  and  it  is  allowed  to  survive  a  few  days, 
certain  results  will  follow.  The  posterior  root  between  the  ganglion  and  the  cord  will 
be  found  to  have  undergone  degeneration,  and  also  its  continuation  upwards  in  the  cord ; 
whereas,  the  anterior  root  and  that  part  of  the  posterior  root  still  in  connection  with  the 
ganglion  will  be  unaffected.  It  is  thus  shown  that  the  ganglion  influeiices  the  nutri- 
tion of  the  sensory  or  afferent  nerves,  and  the  anterior  columns  that  of  the  motor  nerves ; 
in  other  words,  degeneration  goes  on  in  the  direction  of  physiological  activity.  Serres 
observed  the  same  condition  in  a  case  of  disease  of  the  Gasserian  ganglion  ;  he  traced 
degeneration  along  the  decussation  fibrils  to  the  opposite  hemisphere.  So  that  disease 
of  a  sensory  nerve  which  implicates  the  sensory  or  intei'vertebral  ganglia  will  extend 
centripetally  or  adcentrically  as  far  as  its  ultimate  connections,  and  not  unfrequently,  there- 
fore, reaches  as  high  as  the  hemispheres,  the  organ  of  perception  and  thought.  It  is  in 
this  way  we  can  understand  how  insanity  results  from  apparently  very  remote  and  un- 
likely causes.  If  the  degeneration  begins  exclusively  in  one  set  of  sensory  or  motor 
nerve  fibrils,  it  may  be,  and  ofteais,  limited  to  that  set  all  the  way  up  or  down.  We 
thus  understand  how  it  is  that  in  disease  one  set  of  fibrils  is  picked  out,  as  it  were,  from 
the  rest. 

Another  point  of  importance  was  shown  by  Waller,  namely,  that  the  intervertebral 
ganglion  influences  the  nutrition  of  the  distal  sensory  fibrils;  for  when  a  mixed  spinal 
nerve  is  divided  on  its  distal  side,  both  motor  and  sensory  fibrils  undergo  degeneration. 
Hence  the  conclusion  that  excessive  activity  or  exhausting  use  of  the  sensory  nerve  and 
ganglia,  will  affect  the  nutrition  of  the  sensory  fibrils.  This  seems  to  be  the  order  of 
causation  in  certain  kinds  of  locomotor  ataxy. 

The  problem  to  solve  being,  then,  the  order  of  symptoms,  we  have  to  inquire  in  any 
case  where  in  the  nervous  system  the  functional  or  structural  changes  began,  and  then 
follow  the  line  of  physiological  activity.  This  is  already  done  with  much  success  in  cere- 
bral hemiplegias;  but  the  sensory  and  trophical  neuroses  have  had  little  attention  paid 
them  in  this  way.  There  are  two  such  lines  in  all  neuroses — namely,  the  direct  and  the 
decussating — whether  the  line  of  activity  be  centripetal  and  adcentric  (sensory,  afferent) 
or  centrifugal  and  eccentric  (motor,  afferent).  In  either  kind,  single  nerves  and  nerve- 
centres,  or  many  nerves  and  centres  may  be  affected.  Affections  of  the  sensory  nerves 
in  the  latter  case  influence  central  parts  by  what  has  been  termed  radiation  of  sensation 
— the  phrase  meaning  diffusion,  anatomically,  of  the  degeneration  among  the  centres — so 
that  several  functions  are  disordered.     I  will  give  you  illustrations  of  these  views. 

An  injury  to  a  sensory  or  afferent  nerve  may  be  followed  by  varying  centric  disorder 
and  disease.  In  traumatic  tetanus  the  spinal  trophic  system  of  the  flexor  and  extensor 
muscles  of  the  lower  jaw,  limbs,  and  trunk  is  so  affected  that  tonic  convulsions  follow 
upon  a  slight  touch  or  even  change  of  temperature ;  or,  the  injury  may  cause  a  neuralgia 
and  no  tetanus,  but  spasms  and  epileptic  convulsious ;  or  there  may  be  no  neuralgia, 
only  illusive  sensations,  as  an  aura,  numbness,  and  yet  centric  encephalic  disorders  re- 
sult ;  or,  there  may  be  no  change  perceptible  by  the  patient,  and  yet  there  may  be  various 
vesanise,  such  as  the  so-called  "masked"  epilepsy,  mania,  melancholia.  I  give  you  as 
an  illustration  an  instructive  railway  case.  On  March  24,  1866,  a  house-agent  and  tax- 
collector,  aged  60,  weighing  22  stones,  was  holding  on  a  railway  carriage,  when  the  guard 


DEVELOPMENT    OF   THE   NERVOUS   SYSTEM    BY   EVOLUTION.         345 

crushed  the  end  of  his  finger  by  shutting  the  door,  so  that  a  portion  was  squeezed  off. 
He  suffered  much  from  pain  and  loss  of  blood,  and  reached  home  faint  and  exhausted. 
The  finger  healed,  but  in  the  course  of  a  month  after  the  injury  he  had  a  slight  tetanic 
symptom,  and  in  a  few  days  after  that  a  sort  of  fit.  He  now  complained,  also,  of  numb- 
ness and  strange  sensations  in  his  hand  and  arm,  twitchings  of  the  face,  and  a  sense  of 
weariness  and  loss  of  strength,  so  that,  although  previously  in  robust  health,  he  was  un- 
able to  undergo  even  slight  exertion  without  a  feeling  of  fatigue.  He  resumed  his  office- 
work  for  six  months,  but  got  slowly  worse,  becoming  highly  nervous  and  dreadfully 
depressed.  He  had  next  numbness  of  the  body  and  faintness;  then  by  degrees  his 
powers  of  speech,  of  motion,  and  vision  failed;  and  at  last  he  died,  September  13,  1867, 
nearly  eighteen  months  after  the  accident.  This  is  one  of  the  many  kinds  of  injuries  to  the 
nervous  system  railway  accidents  cause.  What  was  the  probable  pathological  anatomy  ? 
First,  degeneration  of  the  afferent  fibrils  of  the  injured  finger ;  then  of  the  intervertebral 
ganglion ;  then  radiation  thence,  either  upon  other  ganglia,  including  the  Gasserian,  or 
else  upon  the» sensory  structures  of  the  cord;  next  as  a  sequal,  degeneration  either  of 
the  vessels,  or  lymphatics,  or  connective  tissue,  or  of  all,  so  that  the  functions  of  both 
the  sensory  and  motor  sides  of  the  cerebro-spipal  centres  were  abolished.  The  pro- 
gressive disease,  the  age  and  great  weight  of  the  sufferer  lead  to  the  inference  that  the 
degenerations  were  diathetic. 

The  element  of  time  is  a  very  important  point  in  the  diagnosis  and  prognosis  of  this 
class  of  cases;  the  progressive  degeneration  may  extend  over  several  years.  In  July, 
1868,  I  saw  a  captain  in  the  Royal  Navy,  who,  fifteen  years  before,  when  a  midshipman, 
fell  about  eight  feet  as  he  was  descending  Table  Mountain,  Cape  of  Good  Hope.  He 
received  a  scalp  wound,  which  bled  freely,  and  he  thought  he  must  have  been  made  un- 
conscious. The  surgeon  of  his  ship  examined,  but  found  no  fracture,  and  dressed  the 
wound,  which  healed  well.  I  found  an  extensive  scar  on  the  scalp  over  the  curve  of 
the  left  parietal  region,  and  the  surface  slightly  depressed.  This  had  led  some  to  pro- 
pose trephining.  Twelve  years  subsequently  to  the  injury,  he  married,  and  shortly  after 
had  habitual  headaches,  with  mental  depression,  increasing  until  he  became  profoundly 
melancholic.  Rest  from  active  duty  restored  him  to  comparative  health  of  both  body 
and  mind,  but  his  manner  continued  to  be  peculiar.  He,  however,  resumed  charge  of  a 
ship,  and  so  got  involved  in  anxious  and  harassing  night  duties  off  the  Irish  coast,  watch- 
ing the  Fenians.  This  exhausting  work  induced  a  series  of  neuroses  of  the  encephalon, 
which  were  progressively  intensified  into  structural  disease,  until  (when  I  saw  him)  he 
was  weak  of  mind,  incapable  of  movement,  passed  urine  and  fseces  involuntarily,  and  had 
great  difficulty  of  articulation,  as  well  as  an  incapacity  to  express  his  ideas  by  appropri- 
ate words,  although  he  easly  smiled  and  laughed.  Early  in  November  of  the  following 
year  he  had  successive  fits  of  convulsions,  became  unconscious,  and  so  died,  sixteen 
years  after  the  injury  to  the  scalp.  Long  as  this  period  may  appear,  I  knew  a  major  whose 
insanity  was  attributed,  and  I  believe  rightly,  to  a  scalp  wound  (sabre  cut)  received  at 
the  battle  of  Waterloo,  thirty  years  previously. 

The  relation  of  these  exciting  and  predisposing  causes  to  time — and  long  time — is  one 
of  the  most  important  points  in  the  observation  of  diseases  of  the  nervous  system.  It 
meets  you  everywhere.  Thus,  the  tendency  to  leprosy  (which  is  a  trophesy)  will  lie 
dormant  in  Europeans  who  have  been  resident  amongst  a  leprous  population,  and  be 
manifested  several  years  after  their  return  to  Europe,  when  exciting  conditions  arise.  If 
the  constitutional  tendencies  be  diathetic,  and  not  acquired,  as  in  the  syphilitic  and 
leprous,  the  climacteric  period  strongly  predisposes.  Any  shock  to  the  nervous  system, 
sometimes  comparatively  slight  in  character,  often  serves  to  weaken  the  dormant  ten- 
dency into  activity.     Marriage,  which  was  thus  operative  in  the  case  of  the  naval  officer. 


34^  PSYCHOLOGICAL   MEDICINE. 

is  specially  influential  when  entered  upon  in  old  age,  or  at  the  climacteric  period,  which 
practically  are  the  periods  when  constitutional  tendencies  to  degenerations  show  them- 
selves. Various  diseases  of  organs  which  have  direct  sjTupathies  with  the  brain  and  cord 
are  thus  apt  to  be  exciting  causes. 

The  decussating  anatomy  of  the  nervous  system  must  be  noted  to  observe  well  these 
various  causes.  In  the  optic  ner^'es  and  their  commissure  we  have  an  illustration  of  both 
the  direct  and  decussating  anatomy  of  all  the  sensory  nerves  of  the  trunk  and  limbs. 
But  afferent  nerves,  which  do  not  naturally  subserve  to  sensation,  will  influence  the  op- 
posite side  of  the  central  axis.  Thus,  there  is  a  connection  between  wasting  of,  one 
ovary,  or  one  testis,  and  wasting  of  the  opposite  half  of  the  cerebellum.  I  think  I  have 
seen  cases  of  a  like  relation  between  disease  of  one  kidney  and  the  opposite  half  of  the 
cerebellum.  An  aflFection  of  one  knee,  or  one  foot,  will  affect  the  kidney  or  the  ovary 
on  the  opposite  side.  ISTay,  it  would  appear  that  the  milk  in  the  two  mammse  is  secreted 
differently  from  this  unilateral  action  of  the  nervous  system.  It  is  well  known  that  in- 
fants will  refuse  the  milk  of  one  breast  and  take  that  of  the  other.  The  decussating  in- 
fluence of  the  injured  ciliary  nerve  of  one  eye  in  inducing  inflammation  of  the  other  is 
another  instructive  example  of  these  trophical  sympathies. 

The  law  of  degeneration,  as  a  retrocession  to  a  lower  kind  of  tissue-change,  may  be 
applied  to  the  pathological  anatomy  and  chemistry  of  organs  and  tissues,  and  enable  us 
the  better  to  understand  the  neurotic  causes  of  morbid  changes.  Thus,  nervous  debility, 
considered  as  a  deficiency  of  trophic  energy,  will  coincide  with  anatomical  and  chemical 
tissue-changes  of  a  lower  tj'pe.  The  production  of  uric  acid,  the  materies  morbi  of  gout, 
is  an  illustration;  it  is  a  normal  chemical  product  of  transformation  of  tissues  in  reptiles 
and  birds ;  in  man  it  is  abnormal,  being  a  retrocession  from  urea.  So  lactic  acid  appears 
to  be  the  result  of  a  retrocession  in  muscular  transformation  from  a  higher  compound. 
Carbons  and  hydrocarbons  as  pigments  and  fats  follow  the  same  law  as  to  place  of  pro- 
duction ;  amyloid  degenerations  are  chitinous. 

In  diathetic  anatomy,  diagnosis,  therapeutics,  the  evolutional  law  of  tissue-anatomy 
upon  which  I  found  my  clinical  view  of  diathesis  is  an  important  guide  to  pathological 
inquiries.  Xothing  can  be  more  vague  than  the  current  doctrines.  Eminent  French 
physicians  speak  of  a  "herpetic"  diathesis,  or  of  an  asthmatic  diathesis — phrases  that 
have  reall)'  no  definite  application  to  tissue-changes,  and  are,  I  think,  worse  than  useless. 
I  must  remind  you  that  the  word  diathesis  means  a  special  putting  together  of  the  funda- 
mental elements  of  the  body,  and  has  no  regard  to  particular  organs  or  viscera,  except  in 
so  far  as  a  particular  tissue  predominates  therein.  The  general  law  to  which  I  refer  is 
that  with  which  you  have  been  made  acquainted  alread}',  and  is  the  order  of  evolution 
of  tissues  in  the  embryo.  This  order  indicates  the  general  or  common  pathological  re- 
lations of  fundamental  tissues.  Firstly,  the  germinal  membrane  appears  as  the  common 
basis  of  all;  then  follows  its  division  into  the  "mucous"  and  "serous"  layers.  Out  of 
the  serous  layer  is  evolved  the  whole  voluntary  motor  apparatus  of  bones,  muscles,  apo- 
neuroses, ligaments,  and  serous  tissues ;  so  that,  as  they  are  all  related  to  each  other  by 
common  origin,  they  are  related  to  each  other  nutritionally  and  diathetically,  and  have 
probably  a  common  relation  to  a  trophical  system.  The  heart  and  vascular  system  have 
a  like  common  evolutional  origin  out  of  the  vascular  layer  of  the  embryo,  which,  how- 
ever, is  a  conjoined  product,  and  has  the  conjoint  qualities  of  the  mucous  and  serous 
layers.  In  diathetic  anatomy  the  difference  is  shown  by  the  distinction  between  gouty 
degenerations  affecting  the  structure  of  the  heart  and  arteries  and  of  the  syno^dal  mem- 
branes of  joints,  and  the  rheumatic,  which  involve  the  fibrous  structures  and  fibrous  peri- 
cardium, and  aortic  and  mitral  valves. 

The  hereditary  tendencies  to  diathetic  diseases  and  degenerations  as  thus  defined  and 


DEVELOPMENT    OF   THE    NERVOUS    SYSTEM    BY   EVOLUTION.  34/ 

fixed  on  an  anatomical  basis  are  more  easily  comprehended  when  we  remember  that 
tissue-changes  in  plants  are  hereditary,  and  that  consequently  it  is  a  regulative  principle, 
as  vis  nervosa,  which,  in  animals  endowed  with  a  nervous  system,  must  be  operative  on 
the  sperm  and  germ-cells.  Now,  a  regulative  energy,  manifested  as  the  "nisus  formati- 
vus,"  is  the  special  property  of  these  minute  portions  of  matter,  and  consequently  it  must 
be  by  a  concentration  of  that  energy  as  vis  nervosa  on  the  genetic  glands,  that  the  pecu- 
liar property  is  supplied.  If,  therefore,  the  innervation  be  defective  in  regard  to  these 
glands,  the  regulative  or  evolutional  power  will  be  defective.  It  is  thus  I  explain  how 
congenital  degenerations  of  structure  and  defects  of  function  and  form  take  place,  from 
deficient  vis  nervosa  in  the  parents,  for  in  these  sperm-cells  and  germ-cells,  as  in  other 
tissues,  the  law  of  degeneration  is  retrocession  to  a  lower  type.  The  nature  and  results 
of  that  defect  in  brain  nutrition  upon  which  hereditary  insanity  depends  is  a  striking 
illustration  of  this  law  of  hereditary  disease  and  defect;  it  is  the  lower  or  animal  appe- 
tites and  instincts  which  crop  out  in  hereditary  insanity. 

Before  we  consider  special  tissue-changes  as  trophesies,  let  us  clearly  understand  what 
we  mean  when  we  speak  of  loss  of  tone,  of  nervous  debility,  and  of  defective  innerva- 
tion. It  is  clear,  from  what  I  have  said,  the  phrases  may  refer  either  to  defective  vital 
energy  in  general,  or  to  defective  regulative  energy  especially,  in  which  case  it  would  be 
to  the  sensory  portion  of  the  nervous  system  we  should  look.  Now,  when  we  are  made 
conscious  of  this  class  of  changes,  pain,  languor,  unease,  and  other  like  feelings  are  ex- 
perienced. Hence,  it  seems  useful  to  inquire  with  reference  to  two  kinds  of  vis  nervosa, 
the  one  as  being  a  molecular  energy,  necessary,  like  heat,  to  all  healthy  tissue-work,  the 
other  regulative  of  its  production  and  application.  This  latter  is,  therefore,  needed,  not 
to  the  end  that  the  tissue  changes  shall  take  place — for  we  have  seen  that  they  can  and 
do  go  on  independently  of  nerve — but  that  they  shall  take  place  in  their  proper  or  normal 
order.  For  example,  if  a  defect  in  a  nerve  or  nerve  centre  (nervous  debility)  is  followed 
by  the  production  of  heat  or  of  uric  acid  in  the  tissue  it  innervates,  these  changes  occur 
because  the  tissue  is  set  free  from  the  regulative  restraint  exercised  by  the  nerve  or  nerve 
centre.  Now,  I  think  clinical  facts  enable  us  thus  to  distinguish  two  kinds  of  trophic  vis 
nervosa  with  corresponding  anatomical  seats,  for  we  can  differentiate  a  regulative  from 
an  executive  kind,  just  as  we  distinguish  a  sensory  and  a  motor.  Here,  again,  the  law  of 
evolution  helps  us  to  a  clearer  understanding.  Just  as  the  trophic  vis  nervosa  is  an  evo- 
lution and  differentiation  of  vital  energy,  so  that  by  which  we  are  conscious  and  act  vol-, 
tionally  is  an  evolution  and  differentiation  of  the  regulative  element  of  trophic  vis  nervosa! 
It  is  that  regulative  principle  which,  as  manifested  in  nutrition  and  development,  was, 
and  indeed  still  is,  termed,  the  anima  psuche,  soul ;  and  as  manifested  in  mental  life,  as 
the  animus,  mind.  This  unity  and  continuity  of  vital  phenomena  is  the  great  truth  of 
medicine,  as  it  ought  ta  be  of  philosophy.  I  do  not  know  in  the  whole  range  of  the 
practice  of  medicine  questions  of  greater  importance  than  those  comprised  in  the  rela- 
tions of  nervous  debility,  in  the  scientific  meaning  of  the  term,  to  states  of  consciousness. 
It  implies  not  only  a  true  knowledge  of  the  relations  of  pain  to  disorder  and  disease, 
whether  in  the  merely  corporeal  forms,  as  tenderness  on  pressure,  hypersesthesia,  neu- 
ralgia, and  of  diminished  and  abolished  sensibility,  as  anaesthesia — for  pain  and  anaes- 
thesia mean  practically  changes  in  the  vis  nervosa — but  of  all  mental  suffering.  Pain 
and  suffering  are  so  commonly  associated  with  disorder  that  the  word  disease  is  its  syno- 
nym, and  the  ancient  word  pathology  means  primarily  the  science  of  suffering.  Hence 
it  is  that  the  psychology  of  pain  and  suffering  is  so  important  a  division  of  the  practice 
of  medicine ;  for  how  can  we  understand  otherwise  the  commonest  experience — e.  g.,  the 
use  of  opium  and  other  sedatives  in  inflammations  and  painful  diseases  ? 

What,  then,  does  pain  mean  in  general  ? 


348  PSYCHOLOGICAL   MEDICINE, 

When  all  the  nutrient  and  mechanical  work  of  the  body  goes  on  according  to  the  rule 
or  norma  of  vital  activity,  the  functions  sfre  said  to  be  normal  and  regular,  and  the  body 
healthy.  Corresponding  to  this  normal  bodily  condition  is  a  mental  condition,  the  feel- 
ing of  health  and  of  being  strong  and  well,  which,  if  contrasted  with  the  mental  state 
that  corresponds  to  what  is  abnormal,  is  pleasurable.  It  has  been  named  variously,  but 
perhaps  the  best  term  is  coensssthesis,  or  common  sensibility;  morbid  states  of  it  are  to 
be  classed  with  the  (zsthes(z.  The  feeling  of  ill-health'  generally,  or  malaise,  or  whatever 
name  be  given  to  that  which  accompanies  what  is  abnormal,  if  there  be  a  feeling  at  all, 
must  have  its  seat  in  a  like  portion  of  the  nerve-centres  as  the  feeling  of  health,  and  this, 
in  accordance  with  the  principle  formerly  laid  down  as  to  the  seat  of  all  conscious 
changes,  must  be  in  the  brain.  Both  states  of  consciousness  correspond  in  regard  to  the 
body  to  that  unity  in  regard  to  mind  which  the  metaphysicians  name  the  "  ego;"  hence 
these  facts  prove,  in  conjunction  with  many  others,  that  there  is  a  trophic  corporeal  cen- 
tre, or  series  of  centres,  just  as  there  is  a  mental  centre  or  series  of  centres.  This  we 
shall  be  able  to  fix  in  a  well-defined  basilar  region  of  the  encephalon,  which  includes 
the  medulla  oblongata,  cerebellum,  and  cerebral  ganglia.  Whatever  may  be  said  of 
local  pain  or  uneasiness  may  be  said  of  these  general  feelings.  Hence  we  must  remem- 
ber as  an  important  fact  in  clinical  observation  that  all  pain,  whether  it  be  local  or  gen- 
eral, and  however  named,  may  be  illusive  as  to  both  seat  and  cause.  It  is  so  with  the 
feeling  as  to  health  and  unhealth,  for,  just  as  in  a  neuralgia,  a  person  may  feel  as  if  he 
had  disease  of  an  organ  when  it  is  healthy,  and  vice  versa  ;  or  when  strong  and  well 
may  feel  ill  and  weak,  and  have  delusions  as  to  the  nature  and  cause  of  his  illusive  illness 
and  weakness.  The  term  "  well  "  means,  as  thus  used,  that  there  is  no  disease  of  organs, 
or  tissues,  or  blood,  as  causes  of  the  feeling  of  illness,  but  that  there  is  central  disorder  or 
disease,  as  a  neurosis,  termed  hypochondriasis  and  hypochondriacal  melancholia.  When 
it  is  not  purely  sensorial  the  painful  state  is  best  named  dysphoria.  These  centric  suffering 
states  (phrenalgise)  are  often  as  painful  as  neuralgise.  I  have  known  hypochondriacs  with 
the  feeling  of  muscular  debility,  yet  strong  in  muscular  development,  as  incapacitated  for 
labor  as  if  really  weak  and  ill  in  their  muscular  system.  On  the  other  hand,  a  patient 
seriously  diseased  may  feel  quite  well — may  have,  indeed,  a  pleasurable  feeling  of  health. 
This  I  term  euphoria ;  it  is  this,  when  manifested  in  cases  of  phthisis,  which  has  been 
termed  the  spes  phthisica.  A  wider  euphoria  is  seen  in  certain  cases  of  insanity  with 
paresis,  in  which,  from  a  particular  kind  of  morbid  brain  nutrition,  the  patient  thinks 
himself  endowed  with  strength  beyond  estimate.  A  third  class  of  cases  are  those  with 
no  sense  or  feeling ;  they  have  apathy  or  aphoria.  Such  persons,  when  very  seriously 
ill — ready,  in  fact,  to  die — make  no  sign  of  feeling  ill.  This  state  occurs  in  dangerous 
cases  of  epidemic  cholera  and  in  fevers  of  a  bad  kind ;  the  patient  will  go  about  wholly 
unconscious  of  serious  illness  or  of  his  impending  death. 

What  is  said  of  these  general  bodily  feelings,  as  commonly  altered  in  disease,  applies 
equally  to  special  bodily  feelings  and  conditions.  Exaltation,  perversion,  abolition  of 
sensibility  have  their  respective  trophic  conditions.  The  results  of  anaesthesia  of  the 
pulmonary  system,  with  evolution  of  motor  vis  nervosa,  are  seen  in  another  form  than 
the  spes  phthisica,  when  tubercular  meningitis  comes  on  in  the  course  of  a  phthisical  case. 
Even  with  large  vomicae  the  cough  and  expectoration  will  cease,  the  voice,  as  the  patient 
raves  deliriously,  becomes  loud  and  strong,  and  the  corporeal  strength  marvellously  de- 
veloped— conditions  all  due  to  changes  in  that  basilar  trophic  region  I  have  hinted  at. 
On  the  other  hand,  there  are  cases  of  insanity  in  which  the  central  trophic  region  is  de- 
fective in  both  sensory  and  executive  or  motor  vis  nervosa,  and  the  results  are  wholly 
different,  manifested  as  low  forms  of  pneumonia,  sometimes  ending  in  gangrene  of  the 
lung ;  precisely  for  the  same  reason  as  sloughing  occurs  in  certain  kinds  of  palsy,  as  in 
typhus  and  paraplegia. 


DEVELOPMENT    OF   THE   NERVOUS    SYSTEM    BY   EVOLUTION.  349 

The  clinical  rule  deducible  from  these  considerations  is,  that  when  we  desire  to  ascer- 
tain the  causes  and  consequences  of  trophic  nervous  debility,  we  inquire  whether  it  is 
the  regulative — i.  e.,  sensory  vis  nervosa  that  is  deficient — or  the  executive — i.  e.,  motor. 
Excessive  use  (functional  activity)  often  determines  this.  Pleasurable  sensory  excitement, 
if  excessive,  is  a  using-up  of  the  sensory  or  regulative  vis  nervosa.  This  is  one  cause  of 
the  debility  induced  by  sexual  excesses,  and  of  locomotor  ataxy  as  a  special  consequence 
of  that  debility.  Pain,  too,  when  excessive,  is  exhausting.  Excessive  thought,  without 
anxiety,  uses  up  the  materials  subservient  to  sensory  excitation;  and  in  this  way  the  regu- 
lative energy  as  regards  the  organs  and  tissues  may  be  defective,  and  neurotic  disorders 
of  all  kinds  follow.  But  excessive  thought,  with  mental  anxiety,  care,  and  pain,  as  grief, 
is  much  more  exhausting,  and  therefore  more  commonly  followed  by  trophesies.  In  the 
exhaustion  caused  by  sexual  excesses  of  males  a  third  element  is  added — viz.,  the  waste 
of  a  highly  evolved  tissue  analogous  in  chemical  composition  and  in  vital  endowments  to 
brain — viz.,  the  sperm-cell  proper.  In  the  sexual  excesses  of  the  female,  this  cause  is 
not  so  operative,  but  chiefly  the  sensorial  exhaustion  of  excessive  pleasurable  excitement. 
In  like  manner,  the  loss  of  blood,  as  in  haemorrhages,  or  of  albuminous  nutrition,  as  in 
albuminuria,  or  the  vi^ant  of  proper  food,  enfeebles  both  the  regulative  and  the  executive 
portions  of  the  trophic  system. 

Induced  in  these  and  other  ways,  nervous  debility  causes  a  variety  of  both  local  and 
general  diseases  of  organs  and  tissues,  which  necessarily  differ  almost  infinitely,  accord- 
ing to  the  kind  of  tissue  and  the  portion  of  the  nervous  system  involved,  and  the  causes 
thereof.  It  will  help  greatly  to  understand  and  classify  and  treat  these  if  we  know  what 
is  general  as  to  nerve  and  tissue,  and  what  is  purely  local.  For  example,  there  is  a  whole 
class  of  gouty  tissue  diseases  which  are  essentially  neurotic,  and  to  be  separated  from 
those  in  which  there  are  local  changes  as  causes.  Before  inquiring,  however,  into  these, 
we  must  first  consider  tissues  in  their  relations  to  the  nervous  system,  and  then  mark  out 
a  clinical  trophic  anatomy  as  a  guide  to  etiology,  diagnosis,  and  therapeutics. 

Dr.  Ferrier,  Speaking  of  the  lesions  of  the  brain,  says:  "The  brain 
may  be  considered  as  divided  into  a  motor  and  a  sensory  zone.  The 
motor  zone  includes  the  convolutions  bounding  the  fissure  of  Ro- 
lando, viz. ;  the  ascending  frontal  and  the  bases  of  the  three  frontal 
convolutions,  the  ascending  parietal  and  postero-parietal  lobule,  and 
the  internal  surface  of  the  same  convolutions  or  para-central  lobule. 
In  this  zone  are  differentiated  centres  for  the  movements  of  the  limbs, 
head  and  eyes,  the  muscles  of  expression,  and  those  of  the  mouth  and 
tongue.  The  centres  of  the  leg  and  foot  are  situated  in  the  postero- 
parietal  lobule,  those  for  the  arm  in  the  upper  third  of  the  ascending 
frontal,  those  for  the  hand  and  wrist  in  the  ascending  parietal,  those 
of  the  facial  muscles  in  the  middle  third  of  the  ascending  frontal  and 
base  of  the  second  frontal,  those  for  the  mouth  and  tongue  at  the 
lower  third  of  the  ascending  frontal  at  the  base  of  the  third  frontal, 
and  for  the  platysma  at  the  lower  extremity  of  the  ascending  parietal, 
just  posterior  to  the  mouth  centre.  The  posterior  third  of  the  upper 
frontal  convolution  and  corresponding  part  of  the  second  frontal, 
contain  the  centre  for  the  lateral  movement  of  the  head  and  eyes. 


350  PSYCHOLOGICAL   MEDICINE. 

The  frontal  regions  in  advance  of  this  centre,  although  anatomically 
related  to  the  motor  division  of  the  internal  capsule,  do  not  seem 
directly  connected  with  motor  manifestations  as  judged  by  the  nega- 
tive effects  either  of  irritation  or  extirpation. 

"  Irritative  lesions  of  the  motor  zone  proper,  such  as  may  be  induced 
by  syphilitic  lesions,  tumors,  spicula  of  bone,  depressed  fractures, 
thickening  of  the  membranes,  etc.,  cause  convulsions,  which  may 
remain  limited  to  one  limb,  or  one  group  of  muscles  without  loss  of 
consciousness,  or  affect  the  whole  of  the  opposite  side  with  loss  of 
consciousness,  or  become  more  or  less  bilateral,  with  all  the  symp- 
toms usually  observed  in  so-called  idiopathic  epilepsy.  If  the  con- 
vulsive phenomena  begin  always  in  the  same  way,  and  if  they  fre- 
quently remain  localized  in  one  limb  or  one  group  of  muscles,  and 
especially  if  paralytic  symptoms  manifest  themselves,  the  exact  po- 
sition of  the  lesion  in  the  opposite  hemisphere  may  be  accurately  di- 
agnosed." (See  cases  by  Hughlings  Jackson,  Clinical  and  Physio- 
logical Researches  on  the  No'voiis  System,  (reprint)  1873  :  Dr.  Dresh- 
field,  Lancet,  February  24,  1877;  Dr.  Brammell,  Brit.  Med.  Journal, 
August  28,  1875  ;  MM.  Charcot  and  Pitres,  Revue  Mensuelle,  1877.) 

Destructive  lesions  of  the  motor  zone  cause  general  or  limited  pa- 
ralysis of  voluntary  motion  in  the  opposite  side  of  the  body,  accord- 
ing as  the  lesion  affects  the  whole  of  the  motor  zone,  or  is  limited 
to  special  centres  within  this  area.  The  causes  of  destructive  lesions 
of  the  cortex  may  be  various — haemorrhage,  laceration  by  wounds, 
etc.  One  of  the  most  common  causes  is  embolism  or  thrombosis  of  the 
arteries  supplying  the  cortical  motor  area.  These  are  derived  from  the 
sylvian  artery  of  the  middle  cerebral.  The  cortical  branches  may 
be  occluded  without  interfering  with  the  circulation  in  the  corpus 
striatum,  which  is  supplied  by  special  branches,  as  shown  by  the  re- 
searches of  Diult  and  Heubner.  When  the  motor  zone  is  affected 
by  general  destructive  lesion,  complete  hemiplegia  of  the  opposite 
side  results,  in  all  respects  like  that  resulting  from  destructive  lesion 
of  the  corpus  striatum  and  anterior  portion  of  the  internal  capsule. 
In  this  form  of  paralysis  the  loss  of  motion  is  most  marked  in  those 
movements  which  are  most  independent,  hence,  the  arm  is  more 
paralyzed  than  the  leg  or  face,  and  the  hand  more  paralyzed  than 
the  shoulder  movements  of  the  arms.  This  has  been  accounted  for 
by  the  fact  that  the  centres  for  bilateral  movement  are  intimately  as- 
sociated in  the  lower  ganglia;  hence,  the  stimulus  from  one  hemi- 
sphere can,  to  a  certain  extent,  call  forth  the  action  of  the  conjoint 


DEVELOPMENT    OF    THE    NERVOUS    SYSTEM    BY   EVOLUTION.  35 1 

motor  nuclei.  The  electrical  contractility  and  nutrition  of  the  mus- 
cles is  not  affected  by  paralysis  of  cerebral  origin.  The  nutrition 
of  the  muscles  may,  however,  suffer  from  disease,  and  frequently  pa- 
ralyses of  cortical  origin  are  followed  after  a  time  by  rigidity  and 
contraction,  accompanied  with  descending  secondary  sclerosis  of 
the  motor  tracts  of  the  crura,  pons  and  lateral  tracts  of  the  spinal 
cord.  In  some  cases  the  descending  degeneration  invades  the  an- 
terior cornua  of  the  spinal  cord,  and  atrophy  of  the  paralyzed  muscles 
ensues.  Occasionally,  from  limited  lesions  of  the  cortical  motor 
area,  complete  hemiplegia  may  occur  on  the  opposite  side  for  the 
time  at  least.  This  is  to  be  explained  by  the  fact  that  sudden  es- 
tablishment of  a  destructive  lesion  may  cause  such  commotion  or 
perturbation  of  the  centres  in  general,  that  their  functions  are  for  the 
time  suspended.  But  in  such  cases  those  centres  which  have  been 
only  functionally  suspended  will  again  resume  their  functions,  and 
the  paralysis  will  disappear,  except  of  those  movements  the  centres  of 
which  have  become  permanently  damaged. 

Limited  lesions  of  the  motor  zone  cause  paralyses  of  those  move- 
ments the  centres  of  which  the  lesion  invades.  The  result  is  not 
complete  hemiplegia,  but  a  monoplegia  or  dissociated  paralysis. 
Hence,  from  a  cortical  lesion  we  may  get  a  paralysis  of  the  arm,  or 
of  the  arm  and  face,  or  of  the  leg  and  arm,  or  of  the  face  alone,  or  of 
the  lateral  movements  of  the  head  and  eyes.  Numerous  examples 
of  these  monoplegias  resulting  from  limited  cortical  lesion  have  been 
collected  by  Charcot  and  Pitres  (Revue  Me nsuei/e,  January,  1877,  et 
seq. ;  abstract  in  Lon.  Med.  Record,  in  April,  1877).  The  morbid  pro- 
cess which,  while  circumscribed  at  first,  causes  a  monoplegia,  may 
advance  to  other  centres,  and  after  a  time  produce  general  hemiple- 
gia of  the  opposite  side.  Hemiplegia  so  resulting  is  a  succession  of 
monoplegise,  and  is  a  sure  indication  of  cortical  disease.  It  is  to  be 
noted  that  destructive  lesion  of  the  mouth  centre  (Broca's  region)  on 
one  side  does  not  cause  paralysis  of  articulation,  owing  to  the  fact 
that  each  centre  has  a  more  or  less  complete  bilateral  influence  over 
the  movements  of  the  mouth  and  tongue.  Destructive  lesion  of 
this  centre  in  the  left  hemisphere  generally  gives  rise  to  aphasia 
without  paralysis  of  articulation. 

In  bilateral  lesions  there  is  both  aphasia  and  paralysis  of  articula- 
tion (see  Dr.  Barlow's  case,  Brit.  Med.  Journal,  1877,  vol.  ii.,  p.  103). 
Limited  cortical  motor  lesions  are  frequently  associated  with  transi- 
tory rigidity  of  the  opposite  side  of  the  body;  and  if  the  lesion  is 


352  PSYCHOLOGICAL    MEDICINE. 

complete,  the  local  paralysis  or  monoplegia  will  remain  permanently, 
and  may  be  accompanied  by  late  rigidity  and  descending  sclerosis  of 
the  motor  tracts,  as  has  been  shown  by  Charcot  (op.  cit.).  These 
monoplegiee  frequently  alternate  with  unilateral  convulsions,  owing  to 
the  morbid  process  occasionally  inducing  irritation  of  the  neighboring 
centres.  Destructive  lesions  of  the  frontal  and  orbital  regions  cause 
no  motor  paralysis  or  any  very  evident  physiological  symptoms.  In 
the  recorded  cases  of  bilateral  lesions,  symptoms  of  dementia  to  a 
greater  or  less  extent  have  been  noted. 

Sensojy  Zone. — From  experiments  on  the  brain  of  monkeys  by 
means  of  the  complemented  methods  of  excitation  by  the  electric 
current,  and  destruction  of  the  gray  matter  of  the  cortex,  the  writer 
has  arrived  at  the  conclusion  that  in  the  regions  lying  posterior  to 
the  motor  zone  there  are  differentiated  centres  of  sight,  hearing, 
touch,  smell,  and  taste.  The  sight  centre  is  situated  in  the  angular 
gyrus,  and  embraces  also  the  occipital  lobe — the  occipito-angular 
region ;  the  centre  of  hearing  is  localized  in  the  superior  temporo- 
spheroidal  convolution ;  the  tactile  centre  is  situated  in  the  hippo- 
campal  region ;  while  the  centres  of  smell  and  taste  are  situated 
together  at  the  lower  parts  of  the  temporo-sphenoidal  lobe. 

Destructive  Lesions. — Unilateral  destruction  of  these  sensory  cen- 
tres does  not,  however,  appear  to  permanently  abolish  sensation  on 
the  opposite  side  of  the  body.  It  is  only  when  the  lesion  is  bilateral 
and  in  corresponding  points  that  the  loss  of  sensation  is  thorough 
and  permanent.  Hence  the  fact  is  to  be  accounted  for,  that  in  man, 
as  a  rule,  unilateral  destructive  lesions  of  the  regions  indicated  are 
latent,  or  not,  so  far  as  at  present  known,  accompanied  by  any  objec- 
tive symptoms.  Numerous  cases  of  this  kind  are  on  record.  No 
secondary  descending  degeneration  of  the  spinal  cord  has  been  ob- 
ser\'ed  in  these  cases.  Until  evidence  is  increased  from  human  pa- 
thology of  the  occurrence  of  loss  of  sensation  from  lesion  of  the 
cortex — and  this  the  writer  holds  is  to  be  looked  for  in  bilateral  de- 
structive lesions — pathologists  in  general  reserve  their  opinion  as  to 
the  explanation  of  the  latency  of  the  lesions  in  question.  But 
though  the  pathological  evidence  in  favor  of  the  localization  of  dis- 
tinct sensory  centres  is  yet  comparatively  slender,  it  is  daily  increas- 
ing. Though  numerous  cases  are  on  record  of  lesions  in  the  angular 
gyri  and  occipital  lobe  without  symptoms  as  regards  vision,  there 
are  others,  more  particularly  of  lesions  of  the  medullary  fibres  of 
this  region,  in  which  hemiopia  towards  the  side  opposite  the  lesion 


DEVELOPMENT    OF   THE    NERVOUS    SYSTEM    BY    EVOLUTION.  353 

has  been  observed.  Some  of  these  cases  may  perhaps  be  explained 
by  direct  or  indirect  lesion  of  the  optic  tract,  but  others  cannot  be 
so  accounted  for.  It  has  been  established  by  the  researches  of  Tiirck, 
Charcot,  etc.,  that  destructive  lesions  of  the  posterior  third  of  the 
internal  capsule,  external  to  the  optic  thalamus,  cause  hemiansesthesia 
of  the  opposite  side  of  the  body.  The  hemiansesthesia  of  organic 
origin  exhibits  the  same  symptoms  as  are  observed  in  what  is  termed 
hysterical  hemiansesthesia.  In  this  condition  there  is  loss  of  tactile 
sensation,  and  more  or  less  complete  loss  of  sight,  hearing,  smell, 
and  taste,  on  the  side  opposite  the  lesion.  The  affection  of  sight, 
which  is  not  accompanied  by  any  change  in  the  eye  discoverable 
by  the  ophthalmoscope,  is  characterized  by  dyschromatopsy,  and  a 
remarkable  contraction  of  the  field  of  vision. 

The  loss  of  hearing  is  very  marked,  if  not  absolute,  and  similarly 
as  regards  smell  and  taste.  It  is  evident  that  the  lesion  situated  in 
the  medullary  fibres  is  not  an  afifection  of  sensory  centres,  and  that 
it  is  simply  a  solution  of  continuity  of  the  centripetal  paths  which  ra- 
diate out  into  the  differentiated  sensory  centres  of  the  cortex.  The 
exact  destination  of  the  special  sensory  paths  the  writer  has  indicated 
above,  and  to  this  the  special  attention  of  physiologists  and  patholo- 
gists should  be  directed.  The  writer  is  likewise  of  opinion  that  the 
loss  of  smell  and  taste,  which  is  occasionally  observed  to  result  from 
a  blow  on  the  occiput  or  vertex,  is  in  many  cases  due  to  injury  by 
counter-stroke  to  the  centres  of  smell  and  taste,  which  are  situated 
in  such  a  position  as  to  be  specially  affected  by  violence  so  directed. 
There  is  no  doubt  that  in  some  cases  the  loss  of  taste  might  be  ac- 
counted for  by  rupture  of  the  olfactory  tracts  or  nerves,  such  as  those 
in  which  taste  is  lost  only  for  flavors,  which  are  compounds  of  smell 
and  taste.  But  there  are  others  in  which  there  has  been  clear  loss 
both  of  smell  and  taste  independently  of  each  other;  cases  which 
can  only  be  satisfactorily  accounted  for,  in  the  writer's  opinion,  in 
the  manner  in  which  he  has  indicated. 

Irritative  Lesions. — Though  the  pathological  evidence  in  reference 
to  the  localization  of  sensory  centres  is  as  yet  but  deficient,  at  least 
as  regards  paralysis  of  the  special  senses  from  destructive  lesion  of 
the  cortex,  there  is  good  reason  for  believing  that  in  cases  of  insanity, 
accompanied  by  sensory  hallucination,  as  also  in  certain  cases  of  epi- 
lepsy ushered  in  by  subjective  sensations,  such  as  flashes  of  light  and 
color,  loud  sounds,  disagreeable  tastes  and  smells,  etc.,  the  phenom- 

23 


354  PSYCHOLOGICAL   MEDICINE. 

ena  are  the  result  of  some  morbid  irritation  of  the  cortical  centres, 
the  anatomical  substrata  of  ideation.* 


CHAPTER  XIX. 


DIPSOMANIA. 


Dipso:mania  is  a  form  of  physical  disease,  and  it  has  been  aptly 
defined  as  "  an  uncontrollable  and  intermittent  impulse  to  take  alco- 
holic stimulants,  or  any  other  agent,  as  opium  or  hashish,  which 
causes  intoxication — in  short,  a  methomania."  We  must  distinguish 
between  this  disease  of  the  nervous  system,  which  Professor  Kraft- 
Ebbing  classifies  as  one  form  of  periodical  insanity,  and  the  physi- 
ological state  in  which  the  individual  merely  chooses  to  indulge  in 
liquor  to  excess.  The  great  question  of  importahce  is  to  distinguish 
the  two  states  or  conditions,  when  the  result,  intemperance,  is  the 
same.  We  must  observe  whether  there  are  symptoms  in  our  patient 
which  can  be  referred  to  primary  disease  of  the  nervous  system. 
We  must  examine  for  hereditary  influences,  which,  when  present, 
lead  us,  of  course,  to  suspect  disease.  Early  development  of  the 
appetite  for  stimulants  points  in  the  same  direction ;  but  the  great 
diagnostic  point  attending  the  disease  is  the  irresistible  impulse  by 
which  the  patient  is  impelled  to  gratify  his  morbid  propensity,  being 
during  the  paroxysm,  blind  to  all  the  higher  emotions  and  pursuing 
a  course  against  which  reason  and  conscience  alike  rebel.  It  is  fre- 
quently seen  that  these  paroxysms  are  preceded  by  considerable 

*  The  attention  of  the  general  practitioner  and  student  is  particularly  directed  to 
these  trustworthy  and  accurate  topographical  descriptions  of  Dr.  Ferrier  of  tlie  lesions 
of  the  convolutions  of  the  brain  and  cortex  cerebri  in  connection  with  observed  clinical 
symptoms.  Their  value  can  hardly  be  overestimated.  It  is  to  such  anatomical  investi- 
gation into  the  topography  and  homologies  of  the  cerebral  convolutions  and  to  experi- 
mental researches  such  as  those  of  Ferrier,  Hitzig,  Charcot,  and  Hughlings- Jackson,  we 
look  for  the  full  and  perfect  understanding  of  the  pathology  of  the  cortex  cerebri.  It 
will  be  seen  that  physiological  experiment  is  in  advance  to-day  of  clinical  observation. 
This  is  due  to  the  vague  manner  of  defining  the  locality  of  lesions.  Ever)-^  physician 
should  endeavor  to  locate  lesions  coming  under  his  notice  and  make  a  careful  study  of 
his  cases. 


DIPSOMANIA.  355 

disturbance  of  the  nervous  system.  The  patient  perspires  and  is 
sleepless,  uneasy  and  prostrated,  and  so  craves  some  stimulant. 

Between  the  paroxysms  he  is  different  from  a  common  drunkard, 
in  oftentimes  disliking  exceedingly  all  stimulants,  and  is  then  a  use- 
ful member  of  society.  The  patients  with  whom  the  medical  pro- 
fession will  come  in  contact  as  sufferers  from  this  disorder  of  the 
nervous  system,  are  not  from  the  lower  classes,  as  many  suppose,  but 
come  chiefly  from  the  brain-working  and  cultured  classes,  and  em- 
brace lawyers,  physicians,  clergymen  and  merchants.  Dipsomania 
has  been  described  under  three  forms  :  acute,  periodic  and  chronic. 
The  acute  form  is  the  rarest,  occurring  only  after  exhausting  diseases 
or  excessive  sexual  indulgence.  The  periodic  form  is  by  far  the 
most  frequent,  and  is  observed  in  persons  who  have  suffered  injury 
to  the  head  or  spine,  females  during  pregnancy,  and  at  the  catame- 
nial  period,  and  also  in  men  whose  brains  are  overworked. 

This  form  is  frequently  hereditary,  and,  consequently,  proportion- 
ately difficult  of  cure.  These  patients  may  abstain  for  weeks  and 
months  from  all  stimulants,  and  may,  during  this  interval,  positively 
dislike  them.  At  last,  however,  the  patient  b'ecomes  uneasy,  listless 
and  depressed ;  is  not  inclined,  to  apply  his  mind,  and  finally  begins 
to  drink  and  continues  until  intoxicated.  It  is  an  interesting  and 
rather  remarkable  fact  that  with  this  class  of  cases,  as  Charles  Lamb, 
in  his  Confessio7is  of  a  Drunkard,  pertinently  remarks  :  "  To  stop 
short  of  that  measure  which  is  sufficient  to  draw  on  torpor  and  sleep, 
the  benumbing,  apoplectic  sleep  of  the  drunkard,  is  to  have  taken 
none  at  all.     The  pain  of  the  self-denial  is  all  one." 

The  patient  continues  this  course  for  ten  days,  or  perhaps  a  fort- 
night, and  then  bitterly  regrets  his  fall.  This  often  runs  on,  if  not 
checked,  into  mania,  and  lapses  into  dementia.  The  last,  and  a  very 
common  form  also,  is  the  chronic  form ;  and  we  have  always  found  this 
to  be  the  most  incurable  form  of  the  disease,  as  the  patients  are  in- 
^cessantly  under  the  irresistible  desire  for  alcoholic  stimulants.  I 
think  the  latter  class  of  cases  require  constant  seclusion  in  an  asylum 
if  they  wish  to  be  free  from  intoxication,  as  a  discharge  or  leave  of 
absenc^  is  always  followed  by  a  repetition  of  the  same  acts.  In  a 
majority  of  cases  of  this  nature,  we  find  hallucinations  of  sight  and 
hearing,  which  oft'Cntimes  produce  very  painful  moral  impressions, 
and  at  times  even  great  terror  in  the  patient.  Cases  of  delirium  tre- 
mens are  excluded  in  these  remarks. 

These  patients  maixifest  confusion  of  thought,  perversion  of  feeling, 


3S6  PSYCHOLOGICAL   MEDICINE. 

suicidal  tendencies,  tremors  of  the  facial  muscles  and  tongue,  anaes- 
thesia of  the  extremities  at  times,  and  very  often  paralytic  symptoms, 
going  on  to  general  paralysis.  The  subject  of  hereditary  metamor- 
phosis of  the  diseases  of  the  nervous  system  is  of  great  importance 
in  this  connection.  As  a  result  of  intemperance  in  the  progenitors, 
we  find  transmitted  to  the  offspring,  allied  but  different  forms  of  the 
neuroses.  It  may  be  dipsomania,  epilepsy,  chorea,  or  actual  insanity, 
or  a  proclivity  to  crime.  It  is,  at  all  events,  an  aptitude  for  some 
form  or  other  of  nervous  disorder,  the  particular  form  being  often  de- 
termined by  causes  subsequent  to  birth.  The  law  of  hereditary  trans- 
mission applies  equally  to  the  victims  of  dipsomania  as  well  as  to 
the  other  insane  classes,  and  is  to  be  studied,  I  think,  in  three  divi- 
sions, according  as  it  is  manifested.  First,  in  predisposition  or  sim- 
ple aptitude,  the  result  of  a  defective  organization,  and  a  weakened 
or  diseased  nervous  system,  as  a  result  of  which,  the  possessor  is 
predisposed,  or  has  a  tendency  to  seek  for  the  relief  obtained  tempo- 
rarily by  alcoholic  stimulants,  when  laboring  under  physical  or  men- 
tal depression ;  second,  in  the  latent  state  or  germ  of  this  disease ; 
and  third,  in  the  actually  developed  disease.  The  first  of  these  states 
the  predisposition  or  aptitude  being  hereditary  in  a  strong  degree, 
is  universally  acknowledged  to  be  the  most  difficult  to  eradicate,  and 
requires  the  wisest  sanitary  conditions  adapted  to  both  body  and 
mind.  Most  people  doubt  the  existence  of  the  second  or  latent  state 
or  germ  of  the  disease,  ignoring  the  law  of  progressive  development, 
and  such  persons  find  it  difficult  to  believe  that  dipsomania  coming 
on  in  maturity,  as  a  result  of  ill-health,  mental  shock,  etc.,  may  have 
originated  in  intemperance  in  the  parent  or  grandparent.  Yet  this 
is  a  fact,  and  is  just  as  easy  of  comprehension  as  the  fact  well  known 
to  neurologists,  that  brain-tissue  degenerations  and  mental  diseases 
may  be  separated  by  long  intervals  of  time,  from  the  too  premature 
and  intense  stimulation  of  the  brain  in  the  young,  which  causes  these 
nervous  diseases.  One  very  important  organic  law  which  should  be 
universally  understood  in  this  connection,  is,  that  morbid  impulses 
and  characteristics  and  traits  may  disappear  in  the  second  generation 
and  break  out  with  renewed  intensity  in  the  third,  although  a  ten- 
dency or  predisposition  may  be  transmitted  to  the  offspring,  and 
under  good  hygienic  and  other  favorable  circumstances,  die  out  and 
fail  to  be  transmitted  any  further.  I  have  remarked  in  my  experi- 
ence with  the  insane,  whether  the  exciting  cause  be  intemperance  or 
something" else,  that  the  cases  most  unlikely  to  recover,  are  those  where 


DIPSOMANIA.  357 

the  insane  temperament  or  diathesis  is  clearly  marked,  and  where 
the  predisposition  to  disease  is  inherited.  Such  patients,  although 
they  may  have  lucid  intervals,  rarely,  if  ever,  entirely  recover. 

I  think  the  insane  impulses  to  drink,  which  overcome  all  the  efforts 
of  the  individual  who  inherits  a  tendency  in  this  direction,  present 
the  same  indications  for  treatment  as  do  the  suicidal  and  homicidal 
impulses,  namely,  seclusion  from  society,  and  the  occasion  of  temp- 
tation, and  the  necessary  restraint  in  a  suitable  institution.  I  do  not 
agree  with  that  class  of  persons  who  hold  that,  under  all  circum- 
stances, the  dipsomaniac  is  to  be  treated  as  an  invalid,  with  the  ut- 
most gentleness  and  forbearance,  and  then,  with  the  strangest  per- 
versity, turn  round  and  tell  you  that  inebriety  is  no  excuse  for  crimi- 
nal actions,  and  fine  and  imprison  perhaps,  the  unhappy  man  who  has 
been  driven  into  the  debauch  by  an  irresistible  craving  for  drink,  when 
properly  he  should  be  treated  as  insane,  and  should  be  sent  to  an 
inebriate  hospital  for  restraint,  treatment  and  cure.  There  are  some 
people  who  appear  to  think  it  no  disgrace  for  the  head  of  the  family 
to  leave  his  home  and  business  and  insanely  hide  himself  away  in 
the  slums  of  the  city  to  drink  until  intoxicated,  and  continue  this 
course  for  several  days,  and  repeat  this  every  three  or  six  months 
until  health,  business  and  family  ties  are  ruined  ;  but  who  would 
foolishly  look  upon  it  as  a  great  disgrace  to  send  him  away  from  home 
for  the  proper  medical  care  and  attention  and  restraint  necessary  for  his 
restoration.  It  should  be  the  province  of  every  conscientious  family 
physician  to  educate  those  families  committed  to  his  charge,  respect- 
ing their  duties  in  such  cases,  and  to  instruct  them  that  inebriety  is  a 
disease  curable  as  other  diseases  are,  if  the  patient  zvill  but  submit  him 
self  to  the  proper  restraint  for  a  sufficient  length  of  time  to  be  cured. 
Our  laws  at  present  fail  lamentably  in  preventing  intemperance,  and 
this  is  due  in  a  great  measure  to  the  false  view  in  which  this  disease 
is  held  by  the  judiciary.  The  different  forms  of  dipsomania  corre- 
spond in  their  manifestations,  and  oftentimes  in  their  causes  to  other 
cases  of  mental  disease,  and  cannot  properly,  I  think,  be  separated 
from  them  as  regards  the  fact  of  the  disease. 

Dipsomania  often  appears  as  a  result  of  the  same  causes  that  ope- 
rate in  the  production  of  other  types  of  mental  disease,  such  as  ill- 
health,  severe  mental  shock,  blows  on  the  head  and  spine,  and  sun- 
stroke. We  are  dealing  in  both  cases  with  abnormal  cerebration ;  in 
the  one  case  associated  with  mania,  melancholia,  dementia  and  idiocy; 
and  in  the  other  with  a  depraved  alcoholic  appetite — an  irresistible 


358  PSYCHOLOGICAL   MEDICINE. 

impulse  which  the  mind  seems  powerless  to  control ;  an  insane  im- 
pulse, just  as  surely  as  a  homicidal  or  a  suicidal  impulse  is  an  insane 
impulse.  I  think  that  when  our  cerebral  pathology,  which  is  as  yet 
in  its  infancy,  becomes  more  generally  understood,  it  will  be  found 
equally  applicable  to  this  as  to  other  forms  of  insanity.  The  terrible 
insane  craving  for  alcoholic  stimulants  is  often  the  result  of  a  lowered 
vitality  or  abnormal  organic  development  of  the  nervous  system  that 
has  descended  from  generation  to  generation,  gaining  in  intensity 
until  it  manifests  itself  by  the  complete  loss  of  self-control  and  active 
inebriety  in  children  and  grandchildren,  after  they  once  taste  intoxi- 
cating liquors  and  indulge  in  them. 

The  blunted  moral  perception  which  so  many  inebriates  exhibit, 
.and  which  renders  them  peculiarly  liable  to  a  relapse  after  they  leave 
an  asylum,  is  to  be  regarded  in  the  same  light,  I  think,  as  the  per- 
verted moral  sense  in  moral  insanity.  In  every  institution  for  the 
insane,  we  find  inmates  who  exhibit  no  obvious  intellectual  aberra- 
tion or  impairment,  the  moral  faculties  being  deranged  while  the  in- 
tellectual faculties  remain  apparently  in  their  normal  condition.  The 
manifestations  of  moral  insanity  may  be  a  simple  perversion  of  some 
sentiment  or  propensity  under  certain  exciting  causes ;  and  I  think 
this  exactly  comprehends  cases  of  dipsomania  with  loss  of  self-con- 
trol and  perversion  of  the  moral  sense.  The  person,  of  course,  is 
aware  that  the  act  is  wrong  in  both  instances,  but  the  control  which 
the  intellect  exercises  over  the  moral  senses  is  overborne  by  the  supe- 
rior force  derived  from  the  disease.  I  have  been  told  many  times, 
by  both  insane  patients  and  dipsomaniacs,  that  the  feeling  on  the 
one  hand  to  commit  some  insane  deed,  and  on  the  other  to  give  way 
to  alcoholic  appetite,  was  contemplated  in  both  instances  with  horror 
and  disgust,  and  at  first  successfully  resisted,  until  at  last,  having 
steadily  increased  in  strength,  it  bore  down  all  opposition.  What 
can  be  a  more  powerful  argument  in  favor  of  the  disease  theory  of 
dipsomania? 

Pathology  of  Dipsomania. — The  basis  of  our  cerebral  pathology  is 
the  fundamental  principle  that  healthy  mental  function  is  dependent 
upon  the  proper  nutrition,  stimulation  and  repose  of  the  brain ;  and 
upon  the  processes  of  waste  and  reparation  being  regularly  and 
properly  maintained.  We  know  that  the  cerebral  cells  are  nourished 
by  the  proper  and  due  supply  of  nutritive  plasma  from  the  blood, 
and  that  this  is  essential  to  healthy  function;  and,  indeed,  the  ulti- 
mate condition  of  mind  with  which  we  are  now  acquainted,  consists 


DIPSOMANIA.  359 

in  the  due  nutrition,  growth  and  renovation  of  the  brain-cells.  If, 
now,  we  take  into  the  system  an  amount  of  alcohol  that  causes  the 
blood  plasma  to  convey  to  the  brain-cells  a  noxious  and  poisonous 
in  place  of  a  nutritive  substance,  stimulating  the  cells  so  as  to  hasten 
the  progress  of  decay  and  waste  beyond  the  power  of  reparation,  and 
impressing  a  pathological  state  on  them,  we  must  inevitably  have 
resulting  a  change  of  healthy  function  and  a  certain  amount  of  dis- 
ease induced.*  Owing  to  the  abuse  of  alcohol  we  have  resulting  a 
change  in  the  chemical  composition  of  the  cerebral  cells  from  the 
standard  of  health,  which  is  the  foundation  of  organic  disease,  as  it 
prevents  and  interrupts  healthy  function.  As  a  result  of  the  over- 
filling of  the  cerebral  vessels  or  hyperaemia  of  the  brain  from  the 

*  It  would  seem  most  probable  that  the  disease  of  inebriety  arises  from  disorder  in 
the  sensory  zone  of  the  brain.  We  have  in  this  disease  an  unnatural  diseased  appetite  or 
taste.  Molecular  changes,  or  a  sub-inflammatory  irritation  of  the  temporo-spheroidal 
lobe  in  its  lower  parts  (the  differentiated  centre  for  smell  and  taste),  would  naturally  pro- 
duce abnormal  sensations  of  taste  and  pervert  it,  inducing  that  periodic  insanity — dip- 
somania— with  its  train  of  unnatural,  inordinate  cravings;  the  indication  of  perversion 
of  normal  nerve-function.  The  disease  of  inebriety,  and  the  alcoholic  diathesis,  depends, 
I  believe,  and  is  the  result  of,  so7ne  morbid  irritation  of  the  cortical  sensory  centres.  I 
think  we  have  good  reason  for  believing  this,  and  its  acceptance  by  the  profession,  as  a 
disease  of  certain  parts  of  the  brain  (a  thing  no  more  difficult  of  belief  than  that  insanity, 
with  sensory  hallucinations,  is  the  result  of  a  similar  lesion),  probably  dependent  upon 
special  molecular  changes,  perverting  brain-function,  a  condition  markedly  hereditary,  as 
are  most  abnormal  conditions  of  the  centric  nervous  system,  and  evinced  outwardly  by 
great  nervous  irritability  or  restlessness,  unnatural  sensations,  an  uncontrollable  desire  for 
alcoholic  stimulants,  and  a  disposition  to  frequent  fits  of  intoxication  (the  more  prominent 
symptoms  of  this  neurosis)  would  do  much  to  render  a  hitherto  vexed  question  conclusive 
and  scientific. 

The  pathological  evidence  in  favor  of  the  fact  that  a  departure  from  a  healthy  structure 
of  the  nervous  apparatus  exists — as  in  mental  disorders — in  dipsomania,  was  at  first  slen- 
der, has  been  yearly  increasing,  and  is  to-day  unanswerable  and  conclusive.  I  also  claim 
that,  with  the  important  and  essential  aid  of  private  hospitals,  we  can  successfully  antago- 
nize the  force  of  this  disease  and  cure  it,  by  restoring  to  its  normal  condition  the  molecu- 
lar nerve  structure  as  in  the  case  of  insanity.  The  treatment  of  this  disease,  therefore,  is 
worthy  of  the  highest  consideration  of  the  entire  profession.  I  have  treated  many  very 
brilliant  professional  and  business  men  (for  it  is  the  finely  organized  brain  and  not  the 
coarsely  developed  one  that  is  affected  by  this  disease)  at  my  private  retreat,  and  by  iso- 
lation, complete  mental  rest,  the  removal  of  all  care  and  responsibility,  a  complete  con- 
trol on  my  part  of  my  patients'  habits  and  surroundings,  and  the  use  of  quinia,  strychnia, 
zinc  and  electricity,  I  have  sent  these  men,  and  not  a  few  women,  back  to  their  places  in 
society  and  business  permanently  cured,  so  that  they  have  achieved  honor  and  success. 
The  term  "  drunkard"  is  worthy  alone  of  the  dense  ignorance  of  fifty  years  ago  respect- 
ing this  disease.  It  is  a  misnomer.  These  persons  are  suffering  from  a  type  of  mental 
disease.  They  want  to  be  cured,  and  they  cajt  be  cured,  and  it  is  the  fault  of  the  physi- 
cian if  they  are  not. 


360  PSYCHOLOGICAL    MEDICINE. 

long-continued  use  of  alcohol,  we  have  at  first  symptoms  of  irrita- 
tation,  due  to  increased  excitability  of  the  nerve-filaments  and  gan- 
glion-cells of  the  brain.  The  symptoms  of  exhaustion  and  depres- 
sion occurring  at  a  later  stage  are  due  to  lost  excitability  of  the 
nerve-filaments  and  ganglion-cells  of  the  brain,  owing  to  a  want  of 
the  proper  supply  of  arterial  oxygenated  blood  to  them.  This  is 
caused  by  the  excessive  cerebral  hypersemia,  the  escape  of  venous 
blood  from  the  brain  being  obstructed  ;  the  result  being  that  no  new 
arterial  blood  can  enter  the  capillaries.  We  may  have  apoplectiform 
or  epileptiform  attacks,  and  paralysis  occurring  in  the  course  of  these 
cerebral  hypersemias,  and  they  may  be  due  either  to  obstructed 
escape  of  venous  blood  or  to  secondary  oedema  of  the  brain,  in 
which  transudation  of  serum  takes  place  into  the  perivascular  spaces 
and  interstitial  tissue  of  the  brain  with  consequent  anaemia.  Until 
very  lately  we  have  known  little  respecting  the  pathology  of  the 
nervous  system,  and  consequently  comparatively  little  information 
has  been  gained  regarding  the  morbid  changes  that  take  place  in  the 
brain  and  its  appendages  as  a  result  of  the  abuse  of  alcohol.  Such 
knowledge  in  this  direction  as  we  do  possess,  shows  that  analogous 
changes  take  place  in  chronic  alcoholism  and  chronic  insanity — 
namely,  atrophy  and  induration  of  the  brain,  and  thickening  and  in- 
filtration of  the  membranes.  The  nerve-cells  have  also  been  found 
to  be  the  seat  of  granular  degeneration  in  some  instances,  and  some 
histologists  have  claimed  to  have  discovered  fatty  degeneration  of 
the  various  brain  elements.  Respecting  the  latter  changes.  Dr.  J. 
Batty  Tuke,  of  Edinburgh,  who  is  one  of  the  most  successful  of 
modern  investigators  in  the  department  of  morbid  cerebral  histology, 
gives  it  as  his  opinion  that  the  application  of  the  various  tests  for  oil 
will  fail  to  detect  the  presence  of  the  so-called  "  free  oil-globules  "  in 
the  substance  of  the  convolutions,  which  he  considers  to  be  but  the 
scattered  debris  of  granular  cells.  According  to  the  great  patholo- 
gist, Rokitansky,  we  find  thickening  and  increase  of  the  pia  mater 
and  arachnoid,  and  permanent  infiltration  of  the  former  and  a  vari- 
cose condition  of  its  vessels,  as  a  result  of  continued  abuse  of  alco- 
hol. As  the  state  of  the  pia  mater  is  unquestionably  closely  related 
to  the  higher  functions  of  the  brain,  the  latter  must  suffer  more  or 
less  as  the  result  of  such  an  abnormal  condition  of  the  former.  If 
there  exists  a  permanently  congested  and  thickened  state  of  the  pia 
mater,  it  is  extremely  probable  that  if  it  becomes  suddenly  turgid  and 
hyperaemic  as  a  result  of  severe  emotional  disturbances,  we  shall 


DIPSOMANIA.  361 

have,  resulting  from  the  increased  pressure  on  the  brain,  coma,  epi- 
leptiform and  apoplectiform  attacks  and  other  grave  nervous  symp- 
toms. It  is  fair  to  conclude  that  in  the  majority  of  cases  the  first 
changes  that  occur  are  repeated  attacks  of  active  cerebral  congestion, 
followed  by  chronic  cerebral  congestion  and  chronic  cerebral  menin- 
gitis ;  and  that,  as  the  disease  assumes  a  chronic  form,  the  brain 
takes  on  a  secondary  change  and  becomes  anaemic,  atrophied,  and 
indurated — a  state  allied  to  cirrhosis.  In  these  cases  of  chronic  me- 
ningitis proceeding  to  atrophy  and  induration — of  which  I  have  seen 
quite  a  number — the  prominent  symptoms  have  been  impairment  of 
memory,  dullness  of  intellect  bordering  on  dementia,  trembling  of 
the  limbs,  tottering  gait,  hesitating  slurring  speech,  and  other  symp- 
toms indicative  of  gradually  progressing  paralysis. 

In  making  autopsies,  where  the  cause  of  death  has  been  owing 
directly  or  indirectly  to  the  abuse  of  alcohol,  I  have  found  cirrhosis 
of  the  liver,  fatty  and  waxy  liver,  cancer  of  the  liver,  chronic  Bright's 
disease,  cancer  of  the  stomach,  and  cancer  of  the  bladder,  and,  in 
one  case  a  gummy  tumor  of  the  dura  mater.*  It  is  doubtless  true 
that  in  many  cases  we  shall  find  upon  examination  no  pathological 
changes  in  the  brain  that  are  demonstrable  by  existing  knowledge 
and  appliances ;  but  I  think  we  should  rather  doubt  the  quality  of 
our  resources  of  observation  than  doubt  the  existence  of  pathologi- 
cal changes  in  this  most  delicate,  sensitive,  and  complex  of  all  organs 
when  we  have  observed  during  life  its  functions  to  be  obviously  per- 
verted, if  not  destroyed.  Having  endeavored  to  prove  that  dipso- 
mania is  a  physical  disease — that  it  is,  in  fact,  a  distinct  type  of 
insanity,  I  pass  in  conclusion  to  the  consideration  of  the  care  of  dip- 
somaniacs. Dipsomania,  which  I  class  as  a  periodic  insanity,  is  more 
troublesome  to  manage  than  simple  insanity,  and  requires,  I  think, 
a  more  perfect  discipline  both  moral  and  physical  than  the  latter. 

In  the  treatment  of  inebriates  we  have  primarily  to  build  up  and 
restore  shattered  constitutions  and  broken-down  nervous  systems. 
We  have  a  class  of  patients  to  deal  with  whose  digestive  powers  are 
weakened,  whose  appetite  is  impaired,  whose  muscular  system  is 
enfeebled,  and  whose  generative  function  is  often  decayed  ;  the  blood 
is  impoverished  and  the  general  nutrition  disordered.  They  are  in- 
directly predisposed  to  the  acquisition  of  nearly  all  diseases,  as  they 
have,  by  long  indulgence  in  alcohol,  lessened  the  power  of  resisting 

*  This  I  consider  as  due  to  syphilis. 


362  PSYCHOLOGICAL   MEDICINE. 

their  causes.  We  have  to  deal  with  the  results  of  a  toxic  poison, 
which  has  resulted  in  more  or  less  pathological  change  in  the  brain 
and  nervous  centres.  We  have  also  to  deal  at  times  with  various 
complications  proceeding  from  the  abuse  of  alcohol,  such  as  cirrhosis 
of  the  liver,  gastritis,  epilepsy,  various  forms  of  dyspepsia,  and  in 
some  cases  with  Bright's  disease.  We  must  place  our  patient  under 
the  most  favorable  hygienic  influences,  provide  for  him  cheerful, 
tranquil,  and  pleasant  surroundings,  repress  cerebral  excitement,  pro- 
cure sleep  for  him,  and  an  abundance  of  fresh  air  and  exercise.  A 
permanent  recovery  depends  largely  upon  allowing  sufficient  time 
for  restoration  of  nerve-power,  mental  tone,  and  physical  vigor,  and 
complete  recuperation  of  the  will-power.  After  a  few  months  of  sys- 
tematic care,  judicious  restraint,  and  enforced  abstinence  from  the 
occasion  of  temptation  until  the  will-power  has  been  restored,  my 
patients  have  generally  recovered  and  have  been  restored  to  society, 
and  I  have  had  a  very  gratifying  degree  of  success  in  my  treat- 
ment of  dipsomania.  We  must  stimulate  inertia,  resist  eveiy  kind 
of  perverted  feeling,  and  check  morbid  impulses ;  and  at  last  we  may, 
if  we  exercise  a  wise  care  and  discrimination,  restore  our  patients  to 
their  homes  and  to  society,  permanently  cured.  In  building  up  the 
system  after  the  wonted  stimulus  has  been  withdrawn,  which  is  inva- 
riably from  the  first,  and  in  combating  the  nerve-exhausting  tenden- 
cies which  are  always  present  in  a  marked  degree  in  such  cases,  in 
addition  to  nerve  sedatives  and  tonics,  we  have  had  surprising  re- 
sults from  the  use  of  electricity  to  the  brain  and  spinal  cord,  and  by 
its  use  we  avoid  the  terrible  nervous  prostration,  which,  as  it  is  well 
known,  follows  the  withdrawal  of  liquor  from  an  inebriate.  Our  pa- 
tients who  have  applied  in  fear  and  trembling,  dreading  the  ordeal 
they  must  pass  through  in  the  beginning  of  treatment  by  reason  of 
such  withdrawal,  have  been  as  much  surprised  as  pleased  to  find  the 
use  of  electricity  supplied  to  the  nervous  system  an  agreeable  and 
invigorating  substitute  for  the  stimulus  which  they  were  debarred 
from  using,  in  such  a  marked  degree  that  little  or  no  suffering  was 
experienced.  As  I  have  found  that  strychnia  was  a  physiological 
antagonist  to  alcohol,  I  have  used  it  largely  and  successfully  in  the 
treatment  of  dipsomania.  I  give  from  gV  to  i^  of  ^  gr^irij  thrice 
daily,  in  combination  with  quinia  and  tincture  gentian  comp.,  so  that 
my  patient  takes  one  or  two  grains  of  quinine  before  each  meal  with 
the  strychnia.     This  makes  a  pleasant  bitter  tonic,  and  one  under 


DIPSOMANIA,  363 

which  patients  recuperate  quickly.  Further  remarks  on  treatment 
will  be  continued  at  the  end  of  this  chapter. 

The  Causes  of  Premature  Mental  Decay  and  Nervous  Exhaustion, 
induced  by  Dipsomania,  and  their  Treatment. — Dipsomania  as  a  dis- 
ease will  never,  in  common  with  other  insanities,  die  out  until  the 
Anglo-Saxon  race  succeeds  in  producing,  what  it  does  not  now  pro- 
duce, a  physique  and  a  brain  capable  of  meeting  successfully  the  de- 
mands that  our  climate  and  civilization  make  upon  it.  To  do  this 
requires  a  bringing  up  of  the  physical  tone  of  the  American  women, 
so  that  the  conformation  shall  be  what  it  should  be  for  the  best  propa- 
gation of  the  species,  and  that  she  shall  have,  what  she  has  not  to- 
day, the  ability  to  furnish  a  suitable  supply  of  wholesome  nutriment 
for  her  offspring,  as  is  the  case  with  German,  English,  Scotch  and 
Irish  women.  To-day  the  vital  temperament  is  too  predominant  and 
too  active,  so  much  so  as  to  require  an  undue  proportion  of  the  nour- 
ishment of  the  body.  Nothing  is  more  certain  than  that  the  physi- 
cal development  of  most  of  our  American  women,  differs  very 
materially  from  the  physiological  standard  upon  which  the  true  law 
of  increase  is  based.  The  remedy  for  all  this  lies  in  the  hands  of 
the  general  family  practitioners,  and  it  is  to  the  subjects  of  diet,  fresh 
air,  sleep  and  tranquillity  of  life  of  the  young  of  the  present  gene- 
ration, and  to  the  general  training  of  the  young  in  educational  in- 
stitutions, that  we  must  look  for  the  production  of  a  better  type  of 
physical  and  mental  stamina.  Parents  should  be  taught  that  for 
their  growing  girls  in  high  schools  more  than  two  hours'  study  out 
of  school  generally  means  weakened  eyesight,  headache,  loss  of 
physical  vigor,  loss  of  sleep  and  appetite,  and  disorders  of  menstru- 
ation. I  think  that  the  influence  of  physical  culture,  especially  ap- 
plied to  women,  and  its  influence  on  the  body  cannot  be  overrated, 
and  that  by  due  attention  to  this  we  shall  see  our  young  women 
graduating  with  health,  with  good  muscular  development,  and  an 
abundance  of  vitality  stored  up  for  the  trying  duties  of  maternity, 
and  with  the  greatest  possible  harmony  of  action  between  the  phys- 
ical and  mental  organization,  tending  to  good  health,  long  life  and 
healthy  progeny. 

Physiology  points  to  the  necessity  among  our  American  women 
of  a  better  developed  physical  system,  more  evenly  balanced  in  all  its 
parts  or  organs,  for  a  greater  harmony  in  the  performance  of  all  their 
functions,  especially  in  reference  to  what  may  not  be  termed  the 
primary  laws  of  nature,  so  that  their  children  may  not  be  weighed 


364  PSYCHOLOGICAL    MEDICINE. 

down  in  the  struggle  of  life  with  a  defective  organization,  but  be 
blest  in  the  inheritance  of  a  perfect  anatomical  and  physiological 
structure  in  all  its  parts  and  organs,  with  a  resulting  harmony  in  the 
performance  of  all  their  functions,  with  perfect  mental  and  physical 
health  and  immunity  from  the  host  of  nervous  diseases  that  affect 
so  large  a  proportion  of  our  people.  It  may  seem  as  if  an  undue 
amount  of  attention  is  spent  in  the  consideration  of  this  question,  but 
having,  by  reason  of  my  specialty,  devoted  much  time  to  the  study 
and  investigation  of  hereditarj^  disease,  I  am  firmly  impressed  that 
in  order  to  eradicate  dipsomania  and  allied  nen^ous  diseases,  and  to 
check  the  increasing  tendency  to  physical  degeneracy  among  Amer- 
ican people,  we  must  aim  at  the  extirpation  of  radical  defects  in  phys- 
ical organization.  At  present  the  average  number  of  children  to  each 
American  family  is  steadily  decreasing  with  each  generation,  and 
the  children  that  are  born  exhibit  a  want  of  vitalit}',  a  want  of  stam- 
ina in  the  constitution,  and  such  a  predominant  tendency  to  physical 
degeneracy  as  threatens  seriously,  it  seems  to  me,  the  perpetuity  of 
our  native  stock. 

The  pathology  of  the  production  of  dipsomania,  as  well  as  most 
other  nervous  diseases,  consists,  primarily,  in  an  interference  with 
the  proper  nutrition  of  the  cerebral  tissues  of  the  foetus,  so  that  even 
during  embrj^'onic  life,  the  brain  undergoes  pathological  changes, 
which  induce  deficient  moral  power,  mental  weakness  and  a  predis- 
position to  the  acquisition  of  all  forms  of  nervous  disease,  there  being 
an  ill-balanced  and  defective  state  of  the  whole  central  nervous  system. 
These  diseases  would  cease  to  exist  if  a  true  healthy  civilization  pre- 
vailed ;  but  inebriety,  in  common  with  other  nervous  diseases,  ovv^es  its 
origin  to  an  artificial  type,  from  wrong  habits,  pernicious  customs  and 
fashions,  and  from  an  unnatural  culture  and  refinement  where  the  laws 
of  health  and  life  are  altogether  too  much  violated.  These  diseases 
have  not  been  the  growth  of  one  generation,  but  of  many,  and  by  the 
laws  of  inheritance  have  become  greatly  increased  and  the  effects  in- 
tensified. To  eradicate  these  evils  and  to  perpetuate  the  race  as  it 
should  be,  there  must  be  sound  and  healthy  stock,  and  not  organi- 
zations impregnated  from  their  ver}^  origin  with  the  seeds  of  disease 
and  premature  decay. 

We  find  in  dipsomania  the  general  symptoms  of  exhausted  ner- 
vous power,  viz. :  general  debility  of  the  body,  inability  to  walk 
even  short  distances  without  fatigue,  general  feeling  of  languor,  un- 
willingness to  make  any  active   exertion,  great  tendency  to  sweat, 


DIPSOMANIA.  365 

more  especially  at  night,  but  also  induced  during  the  day  by  the 
slightest  exertion,  and  often  an  unsteady  gait.  I  have  found  these 
patients  exceedingly  prone  to  neuralgia.  The  explanation  of  this  is 
probably  due  to  the  fact  that  there  exists  in  such  cases  a  warm,  ir- 
ritable, hypersensitive  condition  of  the  sensory  nerve-cells  of  the 
central  sensory  tract,  which  is  the  sole  seat  of  true  nervous  sensi- 
bility. The  central  nervous  system  is  affected,  beyond  all  doubt,  by 
excessive  drinking,  and  the  degeneration  thus  produced,  I  regard  as 
a  powerful  predisposer  of  neuralgia  of  the  inveterate  type.  Aside 
from  the  direct  influence  impressed  on  the  nerve-centres,  I  think  that 
this  irritable  and  hypersensitive  condition  of  the  central  sensory 
tract  is  often  induced  by  visceral  irritative  disease  of  the  stomach, 
kidneys  or  liver,  so  frequently  existing  in  inebriates,  which  almost 
necessarily  affects  the  sensory  nerves  which  ramify  in  these  organs, 
and  from  these  diseased  nerves  a  more  or  less  steady  stream  of  irrita- 
tive and  wearing  nervous  impressions  is  transmitted,  practically  with- 
out cessation,  to  certain  parts  of  the  sensory  tract,  to  which  the  sen- 
sory nerves  from  any  given  part  may  go,  and  as  a  result,  sooner  or 
later  the  central  sensory  nerve-cells  are  brought  into  that  degree  of 
nutritional  disturbance  which  is  the  fundamental  factor  in  neuralgia. 
The  real  seat  of  these  severe  neuralgias,  from  which  so  many  dipso- 
maniacs suffer,  is  rarely,  if  ever,  in  the  peripheral  nerves  of  the  af- 
fected region,  but  in  the  central  nervous  apparatus. 

The  heart's  action  is  weak,  often  irregular,  accompanied  by  palpi- 
tation, and  not  unfrequently  with  symptoms  of  indigestion.  A 
change  has  also  come  over  the  man's  mind,  so  that  the  very  morale 
is  changed.  At  one  moment  he  may  be  very  joyous  and  exci- 
table, and  then  he  will  become  greatly  depressed.  He  will  be  very 
friendly  and  anon  very  hostile.  He  will  be  so  obstinate  that  noth- 
ing can  overcome  his  determination,  and  at  other  times  you  may 
lead  him  like  a  child.  The  heretofore  ever  ready  and  resolute  man 
manifests  marked  indecision  of  character,  and  in  other  cases  there 
may  be  an  utter  inability  to  fix  the  mind  on  any  one  subject,  or  to 
follow  up  a  train  of  thought  consecutively.  Any  force  to  cause  per- 
manent intellectual  activity  must  be  a  mental  and  not  a  physical  one. 
If  the  force  be  alcohol,  which  it  often  is,  as  it  is  becoming  more  and 
more  the  habit  to  resort  to  it  for  its  temporary  effects  in  this  direc- 
tion, the  rate  of  interest  paid  for  its  use  is  frightful.  Not  alone  is 
there  a  loss  of  tone  in  character  and  blunting  of  moral  perception,  but 
intellectual  discrimination  is  much  impaired,  and  impairment  of  all 


366  PSYCHOLOGICAL    MEDICINE. 

the  mental  faculties  is  almost  inevitable.  The  ideas  are  more  sponta- 
neous, less  under  the  power  of  control  and  any  exertion  requiring 
continuous  mental  effort  soon  becomes  impossible.  There  can  be 
no  doubt  that  alteration  of  the  brain  is  taking  ^\2.c^  pari  passu  with 
these  alterations  of  character.  It  may  be  atrophy,  or  the  circulation 
through  the  encephalon  may  be  checked  or  impeded  by  ossification 
or  softening  of  the  cerebral  arteries,  or  some  disease  of  the  heart 
itself,  or  the  neurine  may  be  undergoing  a  change,  particularly  on 
its  peripheral  surface,  as  well  as  on  the  surface  of  its  ventricles  or 
cavities.  The  convolutions  become  paler  and  the  furrows  shallov/er. 
The  weight  of  the  whole  cerebrum  and  cerebellum  is  lighter  and 
less  complex.  Softening  of  a  very  delicate  nature,  so  delicate  as  only 
to  be  detected  post-mortem,  by  letting  a  little  stream  of  water  flow 
gently  over  the  surface  of  the  brain,  may  be  taking  place,  or,  what  is 
very  likely,  and  is  often  passed  by  unnoticed,  because  discernable 
only  to  a  well-practised  eye,  which  may  not  be  present  at  the  right 
moment  for  observing  its  attack,  is  a  very  slight  fit  of  apoplexy  and 
paralysis,  so  slight  indeed,  that  it  occurs  and  passes  away  unnoticed 
and  unperceived,  and  is  recognized  only  in  its  after-consequences 
and  permanent  effects.  From  such  an  occurrence,  though  loss  of 
life  does  not  ensue  immediately,  yet  in  its  ultimate  effects  it  is  soon- 
er or  later  fatal. 

The  patient  is  an  altered  man  and  never  recovers  himself.  So  del- 
icate is  the  tracery  of  the  nervous  structure,  that  the  damage  of  a 
single  fibre  or  set  of  fibres  destroys  the  unity  of  the  whole.  There 
are  generally  three  things  present  that  lead  to  these  attacks  of  cere- 
bral hsemorrhage,  and  as  these  attacks  play  a  very  important  part 
in  the  production  of  premature  mental  decay  in  inebriates,  it  is  de- 
sirable to  thoroughly  understand  them  and  estimate  their  impor- 
tance. The  three  things  alluded  to  are  hypertrophy  of  the  left  ven- 
tricle of  the  heart,  chronic  disease  of  the  kidneys,  and  finally,  degen- 
erated cerebral  arteries.  The  hypertrophy  of  the  heart  is  a  simple 
hypertrophy  of  the  left  ventricle,  the  wall  of  the  ventricle  being 
thickened  without  any  dilatation,  although  in  exceptional  instances 
dilatation  may  ensue.  The  blood  in  inebriety  is  more  or  less  noxious 
to  the  tissues,  since  it  contains  alcohol,  and  its  passage  into  the  cap- 
illaries is  undoubtedly  resisted  by  contraction  of  the  small  arteries, 
the  vessels  most  rich  in  muscular  tissue.  The  muscular  coat  of 
these  vessels,  therefore,  is  hypertrophied  in  antagonism  to  the  heart. 
Since  the  small  arteries  are  hypertrophied  throughout  the  body,  the 


DIPSOMANIA.  367 

obstructions,  though  each  is  slight,  are  in  their  sum  total  so  large, 
that  in  order  that  the  circulation  may  be  carried  on  efficiently,  hyper- 
trophy of  the  heart  must  ensue. 

There  may  be,  doubtless,  degenerative  changes  in  the  small  arte- 
ries, so  that  there  is  increased  bulk  with  altered  structure.  It 
should  not  be  assumed,  I  think,  as  it  often  is,  that  all  the  processes 
leading  to  cerebral  haemorrhage  and  apoplexy  are  of  a  degenerative 
origin,  as  there  can  be  no  reasonable  doubt  that  the  presence  of  alco- 
hol sets  up  a  condition  of  sub-inflammatory  irritation,  which  plays  a 
very  important  part  in  the  production  of  cerebral  haemorrhage.  The 
sub-inflammatory  irritation  causes  the  arteries  to  lose  much  of  their 
elasticity  and  to  become  permanently  wider,  longer,  and  more  tortu- 
ous. This  absence  of  elasticity  of  the  larger  arteries,  becomes  by 
the  withdrawal  of  the  aid  to  the  circulation  in  equalizing  the  flow  of 
the  blood,  an  important  factor  in  leading  to  rupture  of  the  smaller 
arteries.  When  the  brain  wastes  slowly,  as  it  often  does,  the  dilata- 
tion of  the  vessels  and  the  increase  in  the  quantity  of  the  cerebro- 
spinal fluid  favors  rupture  very  decidedly.  There  can  be  no  doubt 
that  the  occurrence  of  cerebral  haemorrhage  in  inebriates,  resulting 
from  abnormal  strains,  would  be  much  more  frequent  were  it  not  for 
the  provisions  which  nature  has  made  for  the  protection  of  the  brain 
from  suddenly  increased  afflux.  The  turns  of  the  carotid  and  verte- 
bral arteries,  the  free  anastomosis  of  the  circle  of  Willis,  and  the  small 
size  of  the  arteries  beyond  that  circle,  before  they  enter  the  brain 
substance,  all  tend  to  protect  the  brain.  The  perivascular  canals  also 
exercise  a  protective  influence  over  the  vessels  they  surround,  and  in 
the  corpus  striatum,  where  cerebral  haemorrhage  is  especially  liable 
to  occur,  as  its  vessels  are  not  capillary  in  size  and  proceed  from  the 
middle  cerebral  artery,  which  is  almost  the  continuation  of  the  inter- 
nal carotid,  we  find  the  perivascular  sheaths  of  very  large  size. 
When  I  say,  then,  that  I  consider  one  of  the  principal  causes,  if  not 
the  principal  cause  of  premature  decay  occurring  in  inebriates  to  be 
the  occurrence  of  cerebral  haemorrhage,  or  apoplexy  resulting  from 
degeneration  caused  by  the  poisonous  effects  of  alcohol  upon  the 
tissues,  I  do  not  think  I  overstate  the  actual  facts.  We  generally 
have  associated  in  such  cases  hypertrophy  of  the  left  ventricle  of  the 
heart,  as  I  have  previously  remarked,  chronic  disease  of  the  kidneys 
and  degenerated  arteries.  The  strong  left  ventricle  and  inelastic 
arteries  combine  to  prevent  the  wave  of  blood  sent  to  the  arteries 
from  being  properly  equalized,  and  consequently  the  smaller  arteries 


368  PSYCHOLOGICAL   MEDICINE. 

of  the  brain  which  are  normally  thinner  than  the  arteries  of  other 
parts,  and  which  are  degenerated,  receive  the  impulse  from  the  heart's 
jerks,  and  being  thus  diseased  and  fragile — perhaps  dilated  and  aneur- 
ismal — give  way. 

Before  passing  to  the  question  of  treatment  I  desire  to  briefly  no- 
tice an  interesting  question,  and  one  to  which  very  little  attention  has 
as  yet  been  directed.  The  question  is  that  relating  to  the  degree  of 
moral  or  criminal  responsibility  zuliich  attaches  to  inebriates.  Inebriety 
depends  very  frequently,  as  we  all  know,  upon  an  abnormal  organic 
development  of  the  nervous  system  that  has  descended  from  genera- 
tion to  generation,  gaining  in  intensity  all  the  time.  There  must  cer- 
tainly be  a  modified  responsibility  when  homicidal  or  suicidal  acts 
are  committed  during  periods  of  such  abnormal  cerebration.  In  such 
cases  a  criminal  act  may  be  committed  in  consequence  of  cerebro- 
mental  disease  without  any  apparent  lesion  of  the  perceptive  and  rea- 
soning powers.  In  these  cases,  also,  the  mental  disorder  is  of  a  sud- 
den and  transitory  character,  not  preceded  by  any  symptoms  calcula- 
ted to  excite  suspicion  of  insanity.  It  is  a  transitory  mania,  a  sudden 
paroxysm,  probably  epileptiform  in  nature,  in  which  convulsive  activ- 
ity is  not  reached  except  so  far  as  the  mind  is  concerned,  without 
antecedent  manifestations,  the  duration  of  the  morbid  state  being 
short  and  the  cessation  sudden.  In  these  cases  the  criminal  acts  are 
generally  monstrous,  unpremeditated,  motiveless,  and  entirely  out  of 
keeping  with  the  previous  character  and  habit  of  thought  of  the  indi- 
vidual. Such  attacks  are  short  in  proportion  to  their  violence.  There 
is  an  instantaneous  abeyance  of  reason  and  judgment,  during  which 
period  the  person  is  actuated  by  mad  and  ungovernable  impulses.  I 
would  by  no  means  wish  to  be  understood  as  advancing  the  plea  that 
inebriety  as  a  simple  habit  should  exempt  or  protect  a  man  from  the 
consequences  of  criminal  acts  committed  while  under  its  influence ; 
but  if  he  has  unhappily  inherited  an  abnormal  organic  development 
of  the  nervous  system,  so  that  mental  delusion,  weakness  or  disease 
deprived  him  of  the  power  of  choice,  and  if  we  can  say,  but  for  the 
presence  of  these  morbid  conditions,  the  habit  never  would  have 
been  formed,  we  should  then  look  upon  his  inebriety  as  due  to  men- 
tal disease,  and  hold  him  responsible  accordingly.  In  dipsomania 
we  have  a  true,  uncontrollable,  and  intermittent  impulse  to  take 
alcohol  to  intoxication,  an  irresistible  impulse  which  differs  en- ' 
tirely  from  the  physiological  state  in  which  an  individual  merely 
chooses  to  indulge  in  liquor  to  excess.     The  first  is  periodic,  the 


DIPSOMANIA.  369 

second  a  daily  habit ;  the  first  is  a  disease,  the  latter  a  bad  habit.  If 
we  in  each  individual  case  study  up  its  psychological  history  we 
shall  always  be  enabled  to  cure. 

I  knew  a  very  prominent  lawyer  who  about  once  in  four  or  five 
months  would  drop  his  most  urgent  cases  and  remain  away  from 
home  for  days,  to  gratify  the  irresistible  impulse  to  drink,  which  pe- 
riodically seized  him,  and  made  him  regardless  of  every  considera- 
tion of  business  or  family  ties.  No  one  deplored  this  disease  more 
than  the  patient  himself,  and  no  one  was  more  anxious  than  himself 
to  be  cured  if  such  a  thing  were  possible.  By  my  advice  he  relin- 
quished his  business,  put  himself  under  treatment,  and  at  the  end  of 
six  months  returned  to  his  professional  duties  a  well  man,  and  has 
never  suffered  from  a  relapse,  as  his  will-power  which  had  been 
utterly  destroyed  was  restored,  and  he  avoided  even  the  most  mode- 
rate use  of  alcoholic  liquors,  and  continues  to  do  so  to  the  present 
day.  His  dipsomania  was  the  result  of  a  family  neurosis  and  of 
hard  brain-work  and  consequent  brain  exhaustion,  with  too  little 
sleep  to  renovate  his  nervous  system.  I  regard  this  as  a  case  of  true 
periodic  mental  disorder,  just  as  much  as  if  his  disease  had  been  a 
mania  instead  of  a  dipsomania.  Dipsomania  is  not  a  rare  disease  in 
young  married  women  residing  amid  the  excitement  of  large  cities. 
Nervous  exhaustion,  produced  by  sexual  excess,  and  too  rapid  child- 
bearing,  plays,  I  think,  an  important  rc/^  as  the  exciting  cause  of  the 
dipsomania,  in  these  cases,  which  admit  of  a  prompt  cure  if  the  pa- 
tient be  removed  for  a  few  months  from  her  home  and  placed  under 
judicious  medical  care.  If  in  any  given  case  I  can  prove  to  you  that 
an  inebriate  who  has  committed  some  criminal  act  during  one  of  his 
paroxysms,  has  had  a  paternal  or  maternal  ancestor  in  an  insane 
asylum,  I  certainly  present  to  you  a  strong  reason  for  pausing  before 
you  denounce  the  act  as  the  simple  outgrowth  of  a  vicious  habit. 

Again,  if  a  man  has  committed  an  act  prejudicial  to  himself  and 
others,  during  a  paroxysm  of  dipsomania  which  has  appeared  either 
in  very  early  youth,  or  in  old  age,  after  a  long,  virtuous,  and  tem- 
perate life,  or  after  a  sudden  mental  shock  or  sunstroke,  I  at  once 
negative  to  your  minds  the  hypothesis  of  habitual  drunkenness.* 

*  The  profession  should  understand  that  this  disease  menaces,  necessarily,  not  our 
■lowest  but  our  highest  civilization.  It  is  the  most  brilliant  class  of  men,  our  great  think- 
ers, men  of  great  mental  activity,  with  whom,  as  Dr.  Wright  of  Ohio  has  shown,  the 
an3esthesia  attending  the  use  of  alcohol  blunts  and  assuages  the  too  acute  sensibilities  of 
their  nerves.     It  affords  rest  to  the  overtaxed  mental  faculties,  he  says,  and  moderates 

24 


370  PSYCHOLOGICAL    MEDICINE. 

A  very  interesting  case  from  a  medico-legal  point  of  view  occurred 
a  short  time  since,  in  which  the  writer  was  consulted  as  an  expert. 
A  murder  was  committed  by  a  man  under  the  influence  of  a  small 
quantity  of  stimulus,  which  evidently  induced  a  state  of  temporary 
insanity,  or  an  epileptiform  attack.  The  integrity  of  the  brain  had 
been  affected  by  a  previous  sunstroke,  and  the  man  had  just  recov- 
ered from  quite  a  serious  illness.  It  is  well  known  that  after  a  sun- 
stroke a  small  quantity  of  liquor  acts  very  violently  upon  the  central 
nervous  system,  and  it  might,  therefore,  be  argued  that  he  was  re- 
sponsible for  the  voluntary  act  by  which  he  submitted  himself  to 
the  influence  of  the  intoxicating  liquors.  But  the  facts  of  the  case 
were  that,  previous  to  this  time,  he  had  been  accustomed  to  drink  with 
impunity,  far  more  than  upon  this  occasion  and  had  never  before 
been  intoxicated.  The  man  was,  therefore,  in  a  morbid  state  pro- 
duced by  the  sunstroke,  subject  thereby  to  a  tendency  to  insanity, 
liable  to  be  excited  by  alcohol,  of  which  morbid  state  he  was  igno- 
rant, having  had  no  reason,  from  his  past  experience,  to  believe  that 
such  results  were  likely  to  proceed  from  a  small  quantity  of  alcohol, 
and  with  no  intention  in  his  mind  to  do  more  than  take  a  very  small 

those  excessiA'e  sensibilities  whose  ceaseless  activity  forces  the  mind  to  unresting  labor. 
Dr.  Wright  well  delineates  that  the  men  who  are  threatened  with  this  disease,  and  become 
victims  to  it,  are  the  neurotic  thinkers,  the  men,  who,  from  the  constitutional  debility  of 
their  inhibitory  nervous  faculties,  cannot  control  the  limits  of  their  mental  activity.  My 
friend,  Dr.  Joseph  Parrish,  has  truly  said  that  "  the  fact  that  there  is  a  condition  of  the  ner- 
vous system  with  which  some  men  are  born,  that  predisposes  them  to  seek  alcoholic  indul- 
gence, is  too  well  known  to  admit  of  successful  contradiction."  In  an  address  last  April  be- 
fore the  "  American  Association  for  the  Cure  of  Inebriates,  "  on  the  "  Pathology  of  Inebri- 
ety," I  called  attention  to  the  fact  that  it  is  a  disease  exhibiting  certain  essential,  psychic  and 
physical  signs ;  a  disease  iia  which  the  victims  are  all  more  or  less  irresponsible  as  are 
the  insane  ;  a  disease  in  which  the  tone  and  power  of  the  nerve  centres  is  lost.  A  dis- 
ease perhaps  more  than  any  other  excepting  insanity  requiring  for  its  cure,  time  and  long 
persistent  hygienic  influences  to  restore  the  normal  vaso-motor  condition,  affecting  the 
nutrition  and  circulation  of  the  brain  and  nerve  centres.  Normal  mental  function  depends 
u.pon  cerebral  cellular  health.  Dipsomania  is  eminently  a  disease  depending  upon  cellu- 
lar and  molecular  unhealth  and  it  is  this  abnormal  condition  of  the  centric  nervous  sys- 
tem, demanding  stimulants,  that  is  essentially  the  disease.  Those  who  are  affected  by 
this  diisease  generally  have  an  inherited  neuropathic  constitution  and  exhibit  certain  neur- 
asthenic symptoms  which  are  the  early,  curable,  prodromic  symptoms  of  inebriety.  They 
are  functional  disturbances  of  the  whole  bodily  organism.  There  is  relaxation  of  the 
general  muscular  tone,  cardiac  stimulation  and  palpitation,  local  tremor,  and  respecting 
cerebral  actions,  the  characteristics  of  debility  of  brain  due  to  general  failure  of  the  nor- 
mal nutrition  appropriating  power  of  the  brain,  such  as  morbid  fears  and  dreads,  mor- 
bidly colored  perceptions,  conceptions  and  misconceptions  and  a  timidity,  irresolution, 
and  general  irritability — all  foreign  to  a  healthy  person  and  constituting  the  essential  psy- 
chic signs  of  the  neuropathic  conditions  of  inebriates. 


DIPSOMANIA.  371 

quantity  of  stimulus.  As  you  will  see,  in  this  case  it  seemed  the 
only  proper  way  to  hold  this  man  responsible  for  consequences 
which  an  ordinary  understanding  could  recognize  as  likely  to  follow 
from  immediate  acts.  I  gave  it  as  my  opinion  that  the  murder,  which 
I  will  presently  describe,  was  committed  during  a  transitory  state  of 
moral  epilepsy,  which  was  the  result  of  a  preceding  sunstroke,  the 
immediate  exciting  cause  being  an  attack  of  illness  and  the  taking  of 
a  small  quantity  of  alcoholic  stimulus.  This  state  of  "moral  epi- 
lepsy "  is  a  morbid  affection  of  the  mind  centres,  which  destroys  the 
healthy  co-ordination  of  ideas,  and  occasions  a  spasmodic  or  convul- 
sive mental  action.  The  will  cannot  always  restrain,  however  much 
it  may  strive  to  do  so,  a  morbid  idea  which  has  reached  a  convulsive 
activity,  although  there  may  be  all  the  while  a  clear  consciousness 
of  its  morbid  nature.  The  case  just  alluded  to  had  complained  of 
pains  in  the  head  and  sleeplessness,  which  had  displayed  marked 
periodicity,  and  which  had  been  accompanied  by  great  irritability  of 
temper,  excited  by  trifles,  and  seemingly  unconnected  with  personal 
antipathies.  As  has  been  previously  stated,  the  person  alluded  to 
had  been  suffering  from  quite  a  severe  illness  and,  after  taking  a 
small  quantity  of  alcoholic  stimulus,  went  out  to  walk.  He  met  a 
friend  with  whom  he  had  been  familiar  for  years,  and  a  discussion 
arose  as  to  the  respective  merits  of  certain  politicians,  when,  the  dis- 
cussion becoming  excited,  the  man  drew  a  revolver  and  shot  his 
friend.  He  then  went,  in  a  dazed  and  confused  state,  and  sat  for 
some  hours  upon  a  river  dock,  and  subsequently  went  home,  burst 
into  tears,  and  informed  his  wife  of  the  sad  occurrence,  and  gave 
himself  up  at  the  police  station.  There  was  no  simulation  of  insanity 
by  pretending  to  be  incoherent  or  by  strange  actions,  and  no  attempt 
either  on  the  part  of  himself  or  wife  to  pretend  that  the  act  was  an 
insane  one.  There  was,  however,  a  total  blank  in  the  prisoner's 
mind  respecting  the  events  immediately  preceding  the  pistol-shot, 
which  shot  seemed  to  have  aroused  his  attention  for  the  time,  and  he 
had  no  recollection  of  the  fact  that  he  sat  on  the  dock  for  some  time 
afterwards,  as  he  was  seen  to  do.  Upon  being  consulted,  as  I  have 
stated,  I  gave  it  as  my  opinion  that  there  had  existed,  for  months 
previous  to  the  occurrence,  a  profound  or  affective  derangement 
which,  from  its  marked  periodicity,  was  evidently  epileptiform  in 
character,  and  that  the  sudden  homicidal  outburst  supplied  the  inter- 
pretation of  the  previously  obscure  attacks  of  sudden  derangement. 
There  had  evidently  been  induced  by  the  sunstroke  in  this  case  an 


3/2  PSYCHOLOGICAL    MEDICINE. 

epileptiform  neurosis,  which  had  been  manifesting  itself  for  months, 
chiefly  by  irritability,  suspicion,  moroseness,  and  perversion  of  char- 
acter, with  periodic  exacerbations  of  excitement,  all  foreign  to  the 
man  previous  to  the  attack  of  sunstroke.  There  are  a  great  many 
instances  among  dipsomaniacs  where,  in  an  unconscious  condition, 
persons  progress  from  odd  or  eccentric  actions  to  deeds  of  violence, 
suicide,  or  murder,  being  unable  to  remember  the  circumstances 
afterwards,  and,  therefore,  irresponsible  for  their  actions.  The  ques- 
tion as  to  the  degree  of  mental  responsibility  attaching  to  such  cases 
is  one  of  great  interest  to  psychologists  and  also  to  jurists,  and  one 
to  which  it  is  hoped  in  the  future  much  more  attention  may  be 
directed  than  in  the  past.* 

Treatment. — In  the  treatment  of  nervous  exhaustion  and  prema- 
ture mental  decay  arising  as  the  result  of  dipsomania,  we  should 
primarily  direct  our  attention  to  the  direction  of  the  mental  habits. 
We  should  endeavor  to  provide  constantly  easy  and  pleasant  occu- 
pation of  the  mind,  avoiding  equally  lazy  inaction  or  violent  excite- 
ment. We  have  in  these  cases  to  deal  with  a  worn,  irritable  condi- 
tion of  the  nervous  system — an  unstable  condition  as  regards  its 
nutrition,  its  solidity,  and  its  perfection  of  structure,  which  makes 
our  task  no  light  matter.  We  must  be  very  careful  that  we  make 
our  patients  sleep,  or  we  shall  have  a  preponderance  of  waste  over 

*  We  are  very  much  behind  the  age  in  our  medico-legal  views  of  inebriety.  Mittermaier, 
in  1840,  in  the  American  yiwisf  for  July,  has  been  found  by  my  friend.  Dr.  T.  D.  Crothers 
of  Hartford,  as  enunciating  sound  and  scientific  views  respecting  the  legal  responsibility 
of  inebriates.  Of  course  it  is  perfectly  evident  to  any  unprejudiced  mind,  that  any  dis- 
ease in  which  there  is  abnormal  cerebration,  and  an  abeyance  of  reason  and  judgment, 
where  the  patient  is  deprived,  by  disease,  of  the  power  of  self-control  and  choice  produces 
a  limited  responsibility.  The  healthy  coordination  of  ideas  is  destroyed  exactly  as  in  any 
other  phase  of  mental  disease.  The  late  Dr.  Beard  and  Dr.  Crothers  have  preferred  the 
term  "trance  state"  to  the  condition  I  have  termed  "epileptiform,"  in  which  a  person 
may  be  in  apparently  full  possession  of  his  senses  and  yet  be  as  unconscious  as  if  in  a 
somnambulistic  state. 

In  true  trance,  however,  volition  is  lost  and  there  is  complete  abeyance  of  the  mental 
functions.  I  explain  this  condition  of  abnonnal  psychical  process  in  inebriates  by  which 
intelligence  and  thought  seem  temporarily  paralyzed,  and  consciousness  suspended,  by 
the  sudden  establishment  of  an  irritative  lesion  caused  by  vascular  tonus  of  the  arterioles 
of  both  motor  and  sensory  zones  of  the  cerebral  cortex,  causing  such  commotion  or  per- 
turbation of  the  centres  in  general  that  their  functions  are  for  the  time  partially  suspended. 
We  get  a  paralysis  or  incoordinate  action  of  these  movements,  special  senses  and  ideas, 
the  centres  of  which  in  the  brain  the  lesion  invades.  Being  only  functionally  suspended 
they  again  resume  their  functions  and  the  normal  equilibrium  is  restored  after  a  variable 
period.  Strychnia  in  gL  to  2^5 "gi"-  doses  is  the  best  physiological  antagonist  to  this  state 
of  vascular  tonus  of  the  arterioles  of  the  brain  in  inebriates. 


DIPSOMANIA.  373 

repair  that  will  balk  all  our  efforts.  Our  patients,  by  reason  of  the 
hereditary  factor  generally  present,  cannot,  without  great  danger  to 
themselves,  do  or  endure  what  other  patients  might  safely  do.  It 
will  be  also  necessary  to  supply  the  greatest  amount  of  nutritive 
material  to  the  brain  to  repair  the  undoubtedly  existing  nutritive 
lesion.  In  some  cases  I  have  given  protagon  with  good  results,  and 
in  others  the  acid  phosphates,  with  free  phosphoric  acid,  in  the  form 
devised  by  Dr.  William  Pepper,  of  Philadelphia.  It  has  seemed 
to  me  to  supply  nerve  force  and  to  restore  enfeebled  digestion  very 
excellently  in  dipsomania.  I  have  also  used  a  preparation  of  cod- 
liver  oil  with  the  wheat  phosphates  with  good  results.  We  must 
quiet  all  abnormal  nervous  excitability  and  keep  our  patients  calm 
and  tranquil.  Attention  should  be  paid  to  the  condition  of  the  ex- 
cretory functions  of  the  skin,  kidneys,  and  bowels.  If  there  is  head- 
ache and  drowsiness  such  diuretics  as  the  liq.  am.  acetat.,  with 
spt.  seth.  nitr.  are  indicated.  The  ext.  of  cannabis  indica  has 
also  proved  itself,  in  my  hands,  a  valuable  adjunct  in  doses  of  one- 
quarter  grain  of  the  solid  extract.  Free  exposure,  without  fatigue, 
to  the  fresh  air  cannot  too  strongly  be  insisted  upon.  One  of  the 
most  valuable  remedial  agents  is  phosphorus,  which  I  prescribe  to 
be  administered  in  cod-liver  oil  in  doses  of  from  y-g^o"^h  to  j'^th  of  a 
grain,  after  meals.  The  cod-liver  oil  is  one  of  the  best  nutritive 
remedies,  as  fat  mxust  be  applied  to  the  nutrition  of  the  nervous  sys- 
tem if  this  is  to  be  maintained  in  its  organic  integrity.  The  general 
effects  of  phosphorus  are  those  of  a  stimulant,  but  it  possesses  a  spe- 
cial power  over  the  exhausted  nervous  system.  It  is,  perhaps,  evan- 
escent in  its  effects,  but  is  never  followed  by  a  stage  of  depression 
which  is  noticeable.  It  should  never  be  ordered  on  an  empty 
stomach.  I  have  used  the  phosphorized  elixir  of  calisaya  bark  with 
strychnia  in  many  cases  of  dipsomania  with  good  results.  As  I  have 
previously  remarked,  I  regard  strychnia  as  a  very  valuable  nerve 
tonic  in  dipsomania,  as  it  seems  to  me  to  antagonize  the  effects  of 
alcohol  upon  the  system.  Quinine  is  also  very  valuable.  I  have 
also  obtained  excellent  results  from  the  use  of  phosphide  of  zinc, 
grains  ^V^^'  ^^  combination  with  the  ext.  of  nux  vomica,  in  J-grain 
doses.*  When  there  is  persistent  insomnia  I  am  accustomed  to  rely 
upon  the  use  of  prolonged  warm  baths,  given  at  bedtime,  conjoined, 
when  necessary,  with  the  use  of  the  monobromide  of  camphor  in  doses 

*  Oxide  of  zinc  in  2-grain  doses  ter  die  in  alcoholic  insanity  is  extremely  valuable, 
inducing  healthy  molecular  action  in  the  brain. 


374  PSYCHOLOGICAL   MEDICINE. 

of  4  grains.  I  always  use  the  imported  preparation  (Dr.  Clin's  cap- 
sules). This  admirable  therapeutic  agent  is  one  of  the  most  valua- 
ble remedies  we  possess  in  treating  hysterical  mania,  it  should  be 
given  in  4-grain  doses,  t.  i.  d.,  being  careful  to  order  the  imported 
article,  which  comes  from  Paris.  The  chloro-phosphide  of  arsenic 
(Routh's  formula)  is  a  very  valuable  therapeutic  remedy  to  antago- 
nize the  condition  of  brain-wasting  which  often  threatens  our  patient 
suffering  from  the  nervous  prostration  induced  by  dipsomania.  It 
should  be  given  in  5-minim  doses,  after  meals,  and  gradually  de- 
creased till,  at  the  end  of  six  weeks,  the  patient  is  taking  but  i  minim 
thrice  daily,  which  he  can  continue  for  one  week  more,  and  then 
drop  entirely.  I  come  finally  to  speak  of  the  remedial  agent  which, 
in  my  opinion",  far  surpasses  all  others  in  its  permanent  effects,  and 
which  is  comparatively  little  used.  I  refer  to  the  judicious  use  of 
the  constant  and  induced  currents  of  electricity.  The  essential  dif- 
ference in  the  action  exerted  upon  the  nervous  system  by  the  use  of 
electricity  and  that  produced  by  drugs  very  often  prescribed  is  as 
follows  :  Many  of  the  remedies  commonly  employed  in  the  treatment 
of  nervous  diseases  and  in  dipsomania,  for  the  purpose  of  restoring 
lost  nerve-force,  are  nerz>e  stininlants,  and  not  nerve  tonics  in  the  pro- 
per sense  of  the  term. 

Electricity  is  a  remedial  agent  which  furnishes  us  with  the  means 
of  modifying  the  nutritive  condition  of  parts  deeply  situated,  and  of 
modifying  the  circulation  to  a  greater  extent,  I  think,  than  by  any 
known  agent.  By  the  judicious  employment  of  the  constant  and 
induced  currents,  we  have  it  in  our  power  to  hasten  the  process  of 
nerve-growth  and  nerve-repair,  and  thereby  indirectly  hasten  the  acqui- 
sition of  nerve-power.  The  use  of  electricity  does  not,  I  think,  act  by 
contributing  anything  directly  to  the  growth  or  repair  of  nerve-tissue. 
Its  action,  it  would  seem  most  probable,  is  to  stimulate  and  quicken 
those  processes  on  which  the  material  and  functional  integrity  of  the 
nervous  system  depends.  The  action  of  electricity  is  always  followed 
in  my  practice  by  an  increase  of  strength  and  nerve-force,  and  the 
results  gained  are  gradual  and  permanent;  while  the  use  of  nerve 
stimulants  has  always  seemed  to  me  to  primarily  excite  the  nerve 
activities  proper,  and  not  the  nutritive  processes  upon  which  the 
acquisition  of  power  depends.  The  deceptive  results  obtained  from 
the  use  of  nerve  stimulants,  depends  upon  the  excitation  of  nerve 
activities  and  the  resultant  expenditure  of  nerve-power,  which  is 
followed  by  a  period  of  exhaustion,  varying  in  degree  and  duration. 


DIPSOMANIA.  375 

The  careful  use  of  electricity  has  always  led  in  my  hands  to  an  in- 
crease of  nervous  energy,  while  the  employment  of  nerve  stimulants 
has  appeared  to  me  to  lead,  in  many  instances,  ultimately  to  a  waste 
and  diminution  of  nervous  energy.  In  cases  of  dipsomania  we  have, 
as  I  have  already  remarked,  abnormal  nervous  excitability  conjoined 
with  cerebral  exhaustion,  and  the  two  indications  which  are  urgent 
are,  primarily,  for  increased  rapidity  and  effectiveness  as  regards  the 
process  of  nerve  nutrition ;  and,  secondarily,  to  secure  freedom  from 
excitement  and  diminution  of  nerve  activity,  and  thereby  to  check 
the  waste  of  nerve  structure  and  of  power.  These  indications  we 
can  fulfil  by  the  judicious  use  of  electricity  and  nerve-tonics  more 
certainly  than  by  any  other  means,  there  being  no  other  such  com- 
bined sedative,  restorative  and  refreshant,  to  the  central  nervous  sys- 
tem, and  we  can  thus  successfully  meet  all  the  indications  in  cases 
of  cerebral  exhaustion  and  threatened  mental  disease,  except  that  of 
affording  direct  nutriment  to  the  brain,  which,  as  I  have  before  stated, 
I  endeavor  to  obtain  by  rest,  cod-liver  oil,  phosphorus,  etc.  The 
use  of  electricity  seems  to  supply  to  the  nervous  system,  in  cases 
of  inebriety,  the  stimulus  which  has  been  withdrawn,  my  patients 
having  repeatedly  told  me  that,  while  under  treatment,  they  expe- 
rienced little,  if  any,  of  the  terrible  feelings  produced  by  its  with- 
drawal under  ordinary  circumstances.  I  have  seen  this  so  often 
that  I  advance  it  as  a  proven  scientific  fact,  and  not  as  an  untested 
theory.  I  have  generally  used  both  currents,  the  constant  and  the 
induced  ;  in  the  former  case  using  the  negative  electrode  at  the  pit  of 
the  stomach,  and,  in  the  latter  case,  placing  the  negative  electrode  at 
the  lower  end  of  the  spine,  in  both  instances  applying  the  positive 
pole  to  the  crown  of  the  head ;  cervical  sympathetic  nerve,  reached 
by  passing  the  electrode  down  along  the  anterior  border  of  the 
sterno-cleido-mastoid  muscle  in  neck ;  the  cilio-spinal  centre,  or 
region  over  or  on  each  side  of  the  seventh  cervical  vertebra ;  and  up 
and  down  the  spine,  making  a  seance  of  perhaps  fifteen  or  twenty 
minutes  daily,  and  in  some  cases  twice  a  day.  This  adds  very  much 
to  the  trouble  of  caring  for  these  cases,  as  it  requires  much  time  and 
patience  on  the  part  of  the  physician,  but  the  results  obtained  amply 
repay  one  for  the  extra  time  expended.  I  have  obtained  such  ex- 
cellent results  from  its  use  that  I  hope  other  physicians,  presiding 
over  institutions  similar  to  mine,  may  be  induced  by  my  success  to 
give  this  very  important  remedy  an  extended  trial,  after  which  I  feel 
sure  that  they  will  never  willingly  relinquish  so  effective  an  agent. 


3/6  PSYCHOLOGICAL    MEDICINE. 


CHAPTER   XX. 

HYSTERIA. 

Anything  that  weakens  a  woman  generally  may,  by  altering  the 
relation  of  the  several  nervous  functions,  bring  about  the  condition 
of  nervous  disturbance  known  as  hysteria.  Our  women  are  the  more 
readily  becoming  hysterical  by  reason  of  the  absence  of  a  pliysique 
and  stability  of  nerve-tissue  capable  of  meeting  successfully  the  de- 
mands that  our  climate  and  civilization  make  upon  them.  The  vital 
temperament  is  deficient  in  the  American  woman,  and  the  nervous 
temperament  is  too  predominant  and  too  active,  so  much  so  as  to 
require  an  undue  proportion  of  the  nutrition  of  the  body.  If  we  are 
to  avoid  an  aggravated  type  of  hysteria  in  the  girls  of  the  rising 
generation,  we  must,  by  great  and  continual  attention  to  the  subjects 
of  diet,  fresh  air,  sleep,  and  tranquillity  of  life  of  the  young  endeavor 
to  produce  a  better  type  of  physical  development  and  mental  stamina. 
What  is  especially  needed  is  a  greater  harmony  between  the  physical 
and  mental  organization.  Our  American  women  need  a  better  devel- 
oped physical  system,  more  evenly  balanced  in  all  its  parts  or  organs, 
with  a  greater  harmony  in  the  performance  of  all  its  functions.  The 
principle  characteristics  of  hysteria  consist  in  an  exaggeration  of  invol- 
untary motility  and  a  diminution  of  the  power  of  the  will.  The  vol- 
untary movements  are  not  properly  executed,  while  the  refle.x,  sensa- 
tional, and  emotional  movements  are  abnormally  active.  The  will  is 
determined  by  the  ideas,  feelings,  and  fancies.  There  is  a  malnutrition 
of  the  nervous  system,  so  distinct  that  the  higher  functions  are  im- 
paired. The  lower  functions  exhibit  increased  activity,  while  the 
higher  exhibit  diminished  power.  Hysteria  is  pre-eminently  a 
disease  of  females,  and  is  induced  by  want  of  occupation,  real  or 
fancied,  morbid  states  of  the  reproductive  organs,  conflicting  emo- 
tions, disappointed  affections,  late  hours,  and  unhealthy  and  per- 
verted manner  of  life.  It  is  sometimes  met  with  in  males  as  the 
result  of  over-mental  work,  worry,  and  excitement,  or  dissipation. 
Hysteria  appearing  in  women  generally  comes  on,  for  the  first  time, 
between  the  age  of  commencing  puberty  and  twenty-five  years.  It 
may,  however,  come  on  at  any  time  during  the  life  of  the  individual. 

Of  the  cases  that  have  been  under  my  treatment,  I  have  traced 
emotional  disturbance  as  the  principal  cause  in  the  production  of  the 


HYSTERIA.  377 

hysteria,  and  the  majority  of  the  cases  that  I  have  had  under  treat- 
ment have  been  young  unmarried  women.  I  have  found  the  ovaries 
involved  more  often,  also,  than  the  uterus.  The  evidence  of  this 
may  be  found  in  the  fact  that  they  are  painful  upon  pressure.  The 
mental  condition  of  a  woman  affected  with  hysteria  is  somewhat  pe- 
culiar. The  patient,  when  the  hysterical  feelings  come  upon  her, 
does  not  feel  disposed  to  make  the  slightest  effort  to  resist  them,  and 
yields  to  her  emotions  whatever  they  may  be.  She  will  laugh  or 
cry  on  the  slightest  provocation,  and  is  very  nervous  and  excitable. 
She  cares  nothing  for  her  duties  and  seemingly  takes  pleasure  in  ex- 
aggerating all  her  slight  discomforts  and  annoyances,  and  by  her 
suspicious,  exacting  and  unreasonable  behavior  makes  life  generally 
uncomfortable  to  those  about  her.  She  indignantly  resents  all  at- 
tempts and  efforts  for  her  comfort  and  cure,  and  discards  all  advice 
from  her  best  friends,  but  will  eagerly  listen  to  the  counsel  of  the 
many  friends  who  come  in  to  pity,  sympathize  and  condole  with  her. 
She  will  say  that  for  her  to  do  certain  things  is  absolutely  impossible, 
but  under  the  stimulus  of  strong  desires  or  wishes,  will,  if  unobserved, 
do  precisely  the  things  declared  to  be  impossible.  I  have  repeatedly 
known  hysterical  women  under  the  influence  of  a  dominating  idea, 
to  undergo  severe  fatigue,  and  even  privation,  that  a  healthy  per- 
son would  find  most  arduous  and  difficult  of  accomplishment,  and 
upon  my  next  visit,  the  same  person  would  declare  that  the  slightest 
effort  to  move  her  limbs  was  excruciatingly  painful.  I  have  also 
had  patients  declare  that  they  were  suffering  the  most  frightful  neu- 
ralgia, and  exactly  simulate  a  neuralgic  attack  of  great  severity,  al- 
though the  placid  countenance  and  expression  of  the  mouth  was  a 
convincing  proof  to  the  contrary.  As  a  rule,  I  have  observed  no 
marked  disturbance  of  the  menstrual  functions,  although  my  patients 
generally  attribute  a  very  undue  prominence  to  them  when  stating  their 
cases  to  me.  I  have  also  failed  to  see  that  hysteria  in  women  could 
be  traced  to  sexual  excess.  One  of  the  earliest  symptoms  of  hys- 
teria is  a  condition  of  hyperaesthesia  or  exalted  sensibility.  All  the 
senses  seem  to  be  preternaturally  acute, — hearing,  sight,  smell  and 
taste.  Patients  also  complain  of  pain,  which  they  locate  on  the  top 
of  the  head,  in  the  mammary  region,  the  hypogastric  or  sacral  region 
or  in  the  various  joints.  It  is  a  noticeable  fact  that,  although  a  slight 
touch  on  the  joints  is  much  complained  of,  that  pretty  active 
motion  will  be  borne  without  discomfort.  Hysterical  anaesthesia 
I   have  also  found  existing    in    the    same   instances.     As    regards 


3/8  PSYCHOLOGICAL   MEDICINE. 

the  muscular  system,  we   may  find  an   increase   of  involutary  mus- 
cular activity  and  a  diminution  of  the  voluntary  movements. 

We  find  at  times  in  hospital  patients,  partial  paralysis  of  the  va- 
rious limbs.  Thus  the  leg  or  arm  will  appear  to  be  paralyzed,  or 
the  patient  will  feign  paraplegia,  and  she  generally  watches  very 
carefully  the  effect  of  her  performance  upon  the  bystanders.  Such 
a  patient  will  tumble  down  and  recover  herself  as  a  paraplegic  pa- 
tient could  not  do.  The  nutrition  of  the  affected  limbs  does  not  be- 
come impaired  as  it  does  in  actual  paralysis,  and  as  a  rule  there  is 
unimpaired  electric  sensibility  and  contractility.  We  may  find  in- 
definite disturbances  in  all  parts  of  the  body.  The  general  health 
may  be  good,  and  the  body  very  well  nourished,  or  there  may  be  a 
condition  of  ill  health  and  general  delicacy. 

The  disturbances  of  digestion  are  generally  traceable  to  a  foolish 
diet  and  an  excess  of  stimulants.  This  excess  of  stimulants  not  un- 
frequently  in  cases  coming  under  my  care  from  the  higher  classes  of 
society,  has  gradually  led  to  dipsomania,  which  exists  at  the  time  the 
patient  comes  under  treatment,  and  requires  to  be  combatted  and 
cured.  Excessive  indulgence  in  opium  especially  in  the  form  of 
morphine,  to  the  extent  of  the  opium  habit,  I  have  also  seen  several 
times  complicating  the  state  of  hysteria.  In  the  hysterical  convul- 
sions which  occur,  there  is  no  sudden  loss  of  consciousness.  The 
patient  will  inform  her  nurse  or  whoever  is  near  that  she  "'  is  going 
to  have  a  fit,"  and  a  general  theatrical  effect  follows.  There  is  no 
distortion  of  the  features  as  in  epilepsy,  neither  is  there  dilatation  of 
the  pupil.  The  eyelids  quiver,  and  the  patient  sees  and  often  watches 
the  effect  of  her  "  fit "  upon  her  friends  or  attendants.  There  may  be 
foaming,  but  the  tongue  is  not  bitten  unless  purposely  to  deceive  the 
physician,  as  I  knew  one  patient  to  do.  The  patient  often  utters 
a  loud  scream  as  she  falls,  but  is  very  careful  to  fall  so  as  not  to 
hurt  herself 

The  presence  of  the  hysterical  aura,  commencing  often  in  the  iliac 
region,  spreading  to  the  epigastrium,  causing  nausea  or  vomiting; 
to  the  chest,  causing  palpitation  of  the  heart ;  to  the  throat,  giving 
rise  to  globus  hystericus ;  and  finally  to  the  head  where  it  induces 
noises  in  the  head,  dimness  of  vision  and  clavus :  generally  precedes 
the  hysterical  convulsion,  and  serves  to  distinguish  between  it  and 
the  epileptic  convulsion.  The  larynx  and  air  passages  may  be  in- 
volved to  the  extent  of  aphonia  and  dyspnoea.  Very  often  there  is 
a  loud  barking  cough  which  has  a  very  characteristic  sound.  The  uri- 


HYSTERIA.  379 

nary  organs  may  be  affected,  and  we  may  find  either  retention  of 
urine  or  a  large  secretion  of  pale  limpid  urine.  As  regards  the  re- 
productive system  I  have  found,  as  I  have  remarked,  that  many  hys- 
terical women  are  quite  free  from  menstrual  disorders.  We  may, 
however,  find  amenorrhoea,  dysmenorrhcea,  menorrhagia  and  other 
menstrual  troubles.  Hysteria  as  a  nervous  disease  of  the  brain  may 
appear  in  children,  and  is  a  general  psychoneurosis  with  them.  Its 
principal  predisposing  cause  in  children  is  a  nervous  constitution  or 
temperament,  while  the  most  important  exciting  cause  is  disturbance 
of  the  sexual  organs.  It  is  hereditary  and  comes  from  parents  and 
grandparents.  It  depends  on  the  mental  and  bodily  education  of  the 
child.  Physical  disturbances,  such  as  bad  treatment,  fright  or  fear, 
are  excitants.  Also,  overstraining  of  the  mind  at  school,  and  a  very 
important  exciting  cause  is  seeing  other  children  in  hysterical  at- 
tacks. The  questions  in  diagnosis  are  whether  the  child  is  predis- 
posed to  hysteria,  and  whether  there  is  any  good  reason  for  simula- 
tion. The  general  prognosis  is  not  good,  as  the  symptoms  tend  to 
increase  at  puberty,  and  the  severest  forms  of  hysteria  in  adults  I 
have  traced  back  as  beginning  in  childhood.  We  have  completely 
developed  hysteria  occurring  both  in  boys  and  girls  many  years  be- 
fore puberty.  It  is  rare,  however,  and  the  ground  for  it  may  be  an- 
aemia, chlorosis  or  hereditary  nervousness.  As  to  the  treatment 
of  the  hysteria  of  childhood,  the  symptoms  may  disappear  under  a 
purely  psychical  treatment,  but  we  must  look  to  the  general  constitu- 
tion and  build  it  up  with  protocarb.  of  iron,  associated  with  other  tonics, 
good  diet,  fresh  air,  cold  sponge  baths  with  friction,  and  r&move  all 
predisposing  and  exciting  causes.  We  must  look  out  for  habitual 
headaches  in  school  children,  as  they  lead  to  poverty  of  blood,  loss  of 
cheerfulness  and  mental  vigor,  and  we  may  get  trophic  changes  in 
the  ganglion  cells  of  the  brain  cortex,  caused  by  anaemia  and  passive 
dilatation  of  the  cerebral  bloodvessels  and  consequent  stasis. 

Closely  allied  to  hysteria  are  the  nervous  disorders  dependent  upon 
a  morbid  condition  of  emotion,  of  idea  and  emotion,  or  of  idea  alone. 
Dr.  J.  Russell  Reynolds  has  shown  that  some  of  the  most  serious 
disorders  of  the  nervous  system,  such  as  paralysis,  spasm,  pain  and 
other  altered  sensations  are  thus  dependent. 

These  symptoms,  he  says,  often  exist  for  a  long  time,  appearing 
as  complicated  diseases  of  the  brain  or  spinal  cord.  They  resist 
many  different  kinds  of  treatment,  and  are  alike  unaffected  by  seda- 
tives or  irritants,  by  attention  or  neglect,  and  disappear  entirely  upon 


380  PSYCHOLOGICAL    MEDICINE. 

the  removal  of  the  erroneous  idea.  They  occur  independently  of 
hysteria,  and  are  often  associated  with  debility.  They  are  also  some- 
times associated  with  real  disease  of  the  nervous  centres,  so  that  the 
practitioner  may  be  perplexed  to  know  how  much  of  a  given  case  is 
due  to  organic  lesion  and  how  much  to  morbid  ideation.  He  cites 
the  acute  effects  of  idea  and  emotion  as  appearing  in  the  case  of  the 
butcher  who  was  agonized  almost  past  endurance  by  the  fact  that  a 
flesh-hook  had  caught  itself,  not  in  his  skin,  as  he  thought,  but  only 
in  his  sleeve.  He  says  very  truly  that  we  often  overlook  the 
"chronic"  effects  of  idea  and  emotion  when  they  take  the  form  of 
muscular  and  sensory  disturbance.  The  case  of  a  young  lady  is 
cited,  who  was  admitted  into  his  London  Hospital  with  paraplegia. 
She  had  become  so  gradually,  and  had  lost  flesh  generally  and  to  a 
considerable  extent.  For  two  or  three  months  she  had  been  quite 
unable  to  stand  even  for  a  moment,  and  upon  her  admission  lay  in 
bed  almost  entirely.  She  thought  she  might  get  better.  The  pa- 
ralysis was  quite  complete;  she  could  just  move  her  toes  or  raise 
either  heel  separately  from  the  bed,  while  lying  on  her  back.  There 
was,  however,  no  want  of  control  over  the  sphincters,  no  local  change 
of  nutrition,  the  cutaneous  sensibility  was  perfect,  the  electric  con- 
tractility and  sensibility  were  perfect ;  there  was  no  spasm  either 
tonic  or  chronic ;  there  was  no  pain  either  spontaneous  or  produci- 
ble by  movement  of  limb  or  pressure  on  the  spinal  column,  there 
was  no  evidence  of  tubercular  or  other  cachexia,  there  had  been  no 
blow,  and  there  was  no  hysteria.  Dr.  Reynolds  did  not  consider 
that  this  case  could  be  placed  under  any  of  the  forms  of  spinal  dis- 
ease, and  he  diagnosed  it  as  ideal  paralysis. 

Her  father  had  become  paralytic  suddenly,  and  she  had  nursed 
him  carefully,  had  worked  hard  and  constantly  with  the  idea  of 
paralysis  constantly  on  her  mind,  and  as  her  limbs  often  ached  from 
weariness  and  her  brain  was  tired,  she  became  possessed  with  the 
idea  that  she  might  become  paralyzed  like  her  father.  She  gradu- 
■ally  lost  power  in  her  legs,  and  finally  was  carried  to  the  hospital. 
She  was  told  confidently  that  she  would  soon  be  well,  and  was  given 
a  mild  tonic  and — merely  for  the  mental  impression  as  the  electric 
contractilit}^  was  perfect — faradization  of  the  legs.  Her  back  and 
limbs  were  rubbed  and  she  was  taken  between  two  nurses,  who  acted 
as  crutches,  and  was  walked  five  minutes  e\'ery  four  hours.  The 
second  day  after  treatment  was  commenced  she  could  stand  with  a 


HYSTERIA.  381 

little  support,  at  the  end  of  four  days  could  walk  fairly  well,  and  at 
the  end  of  a  fortnight  v/as  as  strong  and  well  as  ever. 

Another  case  fifteen  years  of  age,  had  been  "  paralyzed "  for 
two  years,  after  typhoid  fever.  She  was  thin,  but  bright  and 
merry.  She  had  never  been  hysterical.  She  was  partially  hemi- 
plegic.  Could  not  stand  a  moment.  Her  legs  would  double  up 
under  her,  and  she  would  drop  upon  her  knees.  When  lying  on  her 
back  she  could  draw  her  knees  upward  briskly  and  strongly.  She 
could  throw  the  foot  down  with  vigor  and  could  move  along  the 
floor  briskly  on  her  hands  and  knees,  dragging  the  legs  after  her, 
with  the  feet  turned  downward  and  the  toes  inward.  The  sensibility 
and  electric  contractility  were  perfect  everywhere.  She  was  put  on 
mild  tonics,  the  legs  were  faradized  for  the  mental  impression,  and 
she  was  walked  between  two  nurses  for  five  minutes  every  few  hours. 
In  one  week  she  could  walk  well  with  no  assistance. 

Those  patients  whose  symptoms  are  the  result  of  idea  or  imagi- 
nation believe  utterly  in  the  reality  of  their  symptoms,  and  will  fol- 
low out  earnestly  any  plan  of  treatment,  when  in  genuine  hysteria  the 
patient  often  wishes  to  and  actually  deceives  those  about  her.  These 
apparently  absolute  paralyses  co-exist  with  perfect  sensibility  of  skin, 
electro-muscular  sensibility  and  contractility,  with  unimpaired  nu- 
trition of  the  muscles  and  the  skin,  and  with  no  sign  of  disease  in 
the  spinal  bones,  and  in  treatment,  while  we  may  get  no  result  from 
ordinary  therapeutics,  we  get  immediate  cure  when  we  adopt  methods 
which  are  directed  to  the  alteration  of  the  patient's  ideas.  We  must 
make  such  patients  walk  at  once,  at  stated  periods,  with  support  on 
each  side,  this  support  to  be  diminished  day  by  day.  We  must  use 
faradization  of  the  muscles  of  the  limbs  for  its  mental  effect  on  our 
patient's  mind,  and  make  those  muscles  contract  vigorously  which 
the  patient  uses  least.  Massage  and  friction  of  the  limbs  may  also 
be  "used,  and  we  can  always  get  prompt  cures  in  these  cases. 

I  have  found  a  very  interesting  letter  from  London,  written  in  the 
year  1680,  by  Dr.  Thomas  Sydenham,  on  hysteria,  and  it  is  interesting 
to  see  that  even  at  that  early  day  Dr.  Sydenham  recognized  the  ex- 
istence of  hysteria  in  men.  I  think  the  description  can  hardly  fail 
to  be  of  interest,  and  before  proceeding  to  the  question  of  treatment 
I  accordingly  insert  the  most  interesting  parts  of  this  letter. 

"  This  disease,  if  I  calculate  right,  most  frequently  occurs  of  all 
chronical  diseases  ;  they  are  half  the  chronical  diseases.  For  very  few 
women,  which  sex  is  the  half  of  grown  people,  are  quite  free  from  every 


382  PSYCHOLOGICAL   MEDICINE. 

assault  of  this  disease,  excepting  those  who,  being  accustomed  to 
labor,  live  hardly;  yea,  many  men  that  live  sedentary  lives,  and  are 
wont  to  study  hard,  are  afflicted  with  the  same  disease.  And  though 
hysteric  symptoms  were  heretofore  supposed  to  come  from  a  vicious 
womb,  yet  if  we  compare  hypochondriac  symptoms,  which  were 
thought  to  proceed  from  obstructions  of  the  spleen  or  bowels,  or 
from  some  other  I  know  not  what  obstruction  ;  an  egg  is  scarce  more 
like  an  egg  than  these  symptoms  are  to  one  another  in  all  respects. 
But  it  must  be  confessed  that  women  are  much  more  inclined  to  this 
disease  than  men,  not  because  the  womb  is  more  faulty  than  any 
other  region  of  the  body,  but  for  reasons  to  be  shown  hereafter. 
Nor  is  this  disease  only  frequent,  but  so  strangely  various  that  it 
resembles  almost  all  the  diseases  poor  mortals  are  inchnable  to;  for 
in  whatever  part  it  seats  itself  it  presently  produces  such  symptoms 
as  belong  to  it ;  and  unless  the  physician  is  very  skilful,  he  will 
be  mistaken  and  think  these  symptoms  come  from  some  essential 
distemper  of  this  or  that  part,  and  not  from  any  hysteric  disease. 
For  instance,  sometimes  it  possesses  the  head,  and  causes  an  apo- 
plexy which  also  ends  in  an  hemiplegy,  and  is  exactly  like  the  apo- 
plexy whereby  corpulent  and  old  people  are  destroyed ;  and  which 
happens  because  the  animal  spirits  are  stopped,  the  cortex  of  the 
brain  being  stuffed  by  a  great  deal  of  phlegm  ;  from  which  cause  the 
apoplexy  of  hysteric  women  does  no  way  seem  to  arise ;  for  it  seizes 
such  very  often  presently  after  delivery,  a  great  quantity  of  blood 
being  at  the  same  time  evacuated  ;  or  it  proceeds  from  hard  labor  or 
some  violent  commotion  of  the  mind.  Sometimes  it  occasions  vio- 
lent convulsions  much  like  the  falling  sickness  ;  the  belly  and  bowels 
swelling  towards  the  throat,  the  sick  struggling  so  violently,  that 
though  at  other  times  her  strength  is  but  ordinary,  she  can  now 
scarce  be  held  by  all  the  strength  of  those  that  are  about  her,  and 
she  mutters  some  odd  and  inarticulate  sounds  and  strikes  her  breast. 
Women  that  are  wont  to  have  this  disease,  commonly  called  mother- 
fits,  are  generally  very  sanguine,  and  have  a  habit  of  body  almost 
like  that  of  a  virago.  Sometimes  it  seizes  the  outward  part  of  the 
head  between  the  pericranium  and  skull,  causing  violent  pain  con- 
tinually fixed  in  one  part,  which  may  be  covered  with  the  top  of  your 
thumb,  and  violent  vomiting  accompanies  this  pain.  I  call  this  kind 
claims  hystericus,  chiefly  affecting  those  that  have  a  chlorosis.  Some- 
times falling  on  the  vital  parts,  it  causes  so  great  a  beating  of  the 
heart  that  the  women  who  are  troubled  with  it  verily  believe  that 


HYSTERIA.  383 

those  that  are  near  may  hear  thumping  on  the  ribs.  This  kind 
chiefly  seizes  those  that  are  of  a  thin  habit  of  body  and  of  a  weak 
constitution,  and  who  look  consumptive,  and  also  young  virgins  that 
have  the  green  sickness. 

"Sometimes  it  seizes  the  lungs  and  the  patient  coughs  almost  with- 
out intermission,  but  expectorates  nothing,  and  though  this  sort  of 
cough  does  not  shake  the  breast  so  violently  as  that  which  is  con- 
vulsive, yet  the  explosions  are  much  more  frequent.  But  this  kind 
of  hysteric  cough  is  very  rare,  and  chiefly  invades  women  that 
abound  with  phlegm.  When  this  disease  seizes  on  one  of  the  kid- 
neys it  plainly  represents,  by  the  pain  it  causes  there,  a  fit  of  the 
stone,  and  not  only  by  that  sort  of  pain  and  by  the  place  it  rages  in, 
but  also  by  violent  vomitings  which  accompany  it,  and  also  for  that 
the  pain  sometimes  extends  itself  through  the  passage  of  the  ureter, 
so  that  it  is  very  hard  to  know  whether  these  symptoms  proceed 
from  the  stone  or  from  some  hysterick  disease,  unless,  perchance, 
some  unlucky  disturbing  of  the  woman's  mind  a  little  before  she  was 
taken  ill,  or  the  vomiting  up  of  green  matter  shows  that  the  symp- 
toms rather  proceed  from  an  hysterick  disease  than  from  the  stone. 
Neither  is  the  bladder  free  from  this  false  symptom,  for  it  not  only 
produces  pain  there,  but  it  also  stops  the  urine  just  as  if  there  were  a 
stone,  whereas  there  is  none.  But  this  last  kind,  seizing  the  bladder, 
happens  very  seldom,  but  that  which  resembles  the  stone  in  the  kid- 
neys is  not  so  rare ;  both  are  accustomed  to  invade  those  women 
who  are  much  weakened  by  hysterick  fits  coming  frequently,  and 
whose  health  of  body  is  much  impaired.  Sometimes,  falling  upon 
the  stomach,  it  occasions  continual  vomiting,  and  sometimes  a  diar- 
rhoea when  it  is  fixed  upon  the  guts,  but  no  pain  accompanies  either 
of  these  symptoms,  though  frequently  in  both  the  green  humour  ap- 
pears. Both  these  kinds  are  familiar  with  those  that  are  much  weak- 
ened by  the  frequent  coming  of  hysterick  fits,  and  as  this  disease 
afflicts  all  the  inward  parts  almost,  so  sometimes  the  outward  parts 
are  also  seized  by  it,  and  the  musculous  flesh,  occasioning  pain,  and 
sometimes  a  tumor  in  the  jaws,  shoulders,  hands,  thighs,  legs,  in 
which  kind  the  tumor  which  swells  the  legs  is  more  conspicuous 
than  the  rest;  but  whereas,  in  hydropsical  tumors,  these  two  things 
may  be  always  observed,  namely,  that  the  swelling  is  most  in  the 
evening,  and  being  pressed  by  the  finger  a  pit  remains.  In  this  tu- 
mor the  swelling  is  most  in  the  morning  ;  neither  does  it  yield  to 
the  finger,  or  leave  any  mark  behind  it,  and  for  the  most  part  it  only 


384  PSYCHOr.OGICAL   MEDICINE. 

swells  one  of  the  legs.  As  to  other  things,  if  you  observe  the  large- 
ness of  it,  or  its  superficies,  it  is  so  very  like  hydropsical  swellings 
that  the  patient  can  scarce  be  persuaded  to  believe  that  it  is  any  other 
disease.  Neither  are  the  teeth,  which  you  will  scarce  believe,  free 
from  the  assault  of  this  disease,  though  they  are  not  hollow  and 
though  there  is  no  apparent  defluxion  that  may  occasion  the  pain, 
yet  it  is  no  whit  gentler,  nor  shorter,  nor  easier  to  be  cured.  But 
those  pains  and  tumors  that  afflict  the  outward  parts  chiefly  fall  upon 
those  women  that  are  in  a  manner  quite  destroyed  by  a  long  series 
of  hysterick  fits  and  by  the  force  of  them.  But  among  all  the  tor- 
ments of  this  disease  there  is  none  so  common  as  a  pain  in  the  back, 
which  most  certainly  all  feel  how  little  soever  they  are  afflicted  with 
the  disease.  IMoreover,  this  is  common  to  the  above-mentioned 
pains,  that  the  place  on  which  they  were  cannot  bear  touching  after 
they  are  gone,  but  is  tender  and  aches  just  as  if  beaten  soundly ;  but 
this  tenderness  goes  off  by  degrees.  And  this  is  worthy  of  observa- 
tion, that  often  a  notable  cold  of  the  external  parts  makes  way  for 
these  symptoms,  which,  for  the  most  part,  goes  not  off  till  the  fit 
ends,  which  cold,  I  have  observed,  is  almost  like  that  by  which  a 
carcase  grows  stiff;  and  yet  the  pulse  is  good.  And,  moreover, 
almost  all  hysterick  women  whom  I  have  taken  care  of  hitherto  com- 
plain of  a  dejection  and  sinking  of  the  spirits,  and  when  they  would 
show  the  place  Avhere  this  contraction  or  sinking  of  the  spirits  is, 
they  point  to  the  region  of  the  lungs.  Lastly,  it  is  known  to  every 
one  that  hysterick  women  sometimes  laugh  excessively  and  sometimes 
cry  as  much  without  any  real  cause  for  either.  But  among  all  the 
symptoms  that  accompany  this  disease  this  is  the  most  proper  and 
almost  inseparable,  viz.:  an  urine  as  clear  as  rock-water,  and  this 
hysterick  women  evacuate  plentifully,  which  I  find,  by  diligent  inquiry, 
is  in  almost  all  th.Q  pathognomojiick  sign  of  this  disease  which  we  call 
hysterick  in  women  and  hypochondriack  in  men ;  and  I  have  some- 
times observed  in  men,  that  presently  after  making  water  of  a  citron 
color  (yea,  almost  the  next  moment),  being  suddenly  seized  with 
some  violent  perturbation  of  the  mind ;  they  presently  void  water  as 
clear  as  crystal  and  in  great  quantity,  with  a  violent  stream,  and  con- 
tinue ill  till  the  urine  comes  to  its  wonted  color,  and  then  the  fit 
goes  off.* 


*  Within  a  week  I  have  been  consulted  by  an  eminent  Southern  physician  for  relief  of 
his  nervous  symptoms,  and  the  most  prominent  of  them  all  was  a  sudden,  violent  gush  of 
pale,  limpid  urine,  in  large  quantity,  whenever  anything  disturbed  his  mind.     He  was 


HYSTERIA.  385 

"And  it  happens  to  all  hysterical  and  hypochondriacal  people  when 
the  disease  has  been  long  upon  them,  that  sometimes  they  belch  up 
ill  fumes  as  often  as  they  eat,  although  they  eat  with  moderation  and 
according  as  they  have  an  appetite;  and  sometimes  the  wind  that 
comes  from  the  stomach  is  sour,  just  like  vinegar,  when  it  comes 
into  the  mouth,  the  concoction  being  much  decayed  and  the  juices 
quite  changed  from  their  natural  state.  Nor  are  they  unhappy  on 
this  account,  viz. :  that  their  bodies  are  so  disordered  and,  as  it  were, 
tottering  like  ruined  houses,  for  their  minds  are  worse  affected  than 
their  bodies,  for  an  incurable  desperation  is  mixed  with  the  very 
nature  of  the  disease.  They  are  very  angry  when  any  one  speaks 
ever  so  little  of  the  hopes  he  has  of  their  recovery,  easily  believing 
that  they  undergo  all  the  miseries  that  can  befall  a  man,  foreboding 
the  most  dreadful  things  to  themselves ;  entertaining  in  their  restless 
and  anxious  breasts,  upon  small  occasions  and  perchance  for  none  at 
all,  fear,  anger,  jealousies,  suspicions,  and  worse  passions  of  the  mind, 
if  any  can  be  worse;  abhorring  all  joy,  hope,  and  mirth;  and  if  any 
of  these  chance  to  happen,  'tis  very  rare  and  soon  flies  away,  and  yet 
does  not  less  disturb  the  mind  than  the  sorrowful  passions ;  and  they 
never  keep  a  Mean — constant  only  to  inconstancy.  Sometimes  they 
love  above  measure  and  presently  hate  the  same  without  any  reason. 
Sometimes  they  intend  to  do  this  or  that,  and  then  presently  alter 
their  intentions  and  begin  quite  the  contrary,  and  yet  they  do  not 
do  that  either ;  so  wavering  are  they  that  their  minds  cannot  be  at 
all  at  rest. 

"  A  day  would  scarce  suffice  to  reckon  up  all  the  symptoms  belong- 
ing to  hysterick  diseases,  so  various  are  they  and  so  contrary  to  one 
another  that  Proteus  had  no  more  shapes  nor  the  chameleon  so  great 
variety  of  colors,  and  I  think  Democritus  was  pretty  right  (though 
he  mistook  the  cause  of  the  disease)  when  he  wrote  in  an  epistle  to 
Hippocrates  that  the  womb  was  the  cause  of  six  hundred  miseries 
and  of  innumerable  calamities.  Nor  are  they  only  very  various,  but 
also  so  irregular  that  they  cannot  be  contained  under  any  uniform 
type,  which  is  usual  in  other  diseases,  for  they  are,  as  it  were,  a  dis- 
orderly heap  of  phenomena,  so  that  it  is  very  hard  to  write  the  his- 
tory of  this  disease,"  etc.,  etc. 

From  this  interesting  account  given  by  Dr.  Sydenham,  in  1680, 
of  the  symptoms  of  hysteria,  we  see  that,  in  many  respects,  it  was 

suffering  from  what  an  eminent  authority  had  diagnosed  as  congestion  of  the  spinal  cord 
but  which  was  decided  hysteria  and  hypochondriasis. — E.  C.  M. 

25 


386  PSYCHOLOGICAL    MEDICINE. 

pretty  v/ell  understood  even  at  that  early  day.  Dr.  Sydenham  evi- 
dently considered  hypochondriasis  and  hysteria  as  identical,  whereas 
we  know  now  that  the  former  has  for  its  chief  manifestation  mental 
depression,  occurring  without  adequate  cause,  and  our  hypochrondriac 
patient  believes  that  he  is  the  victim  of  some  organic  disease,  and, 
furthermore,  that  this  disease  is  markedly  hereditary,  and  comes 
from  a  strong  hereditary  taint  of  insanity.  It  also  appears  in  middle 
life,  whereas  the  latter,  hysteria,  comes  on  generally  between  the  ages 
of  fifteen  and  thirty,  and  occurs  in  women  or  men  not  especially 
descended  from  markedly  insane  families. 

The  following  case  of  general  hysterical  paralysis  very  well  illus- 
trates this  type  of  the  disease  as  it  not  unfrequently  appears,  and  I 
accordingly  insert  it : 

Miss ,  of  Mississippi,  aged  twenty,  was  brought  to  my  private 

hospital  for  nervous  diseases  by  her  family  physician  and  her  brother 
in  the  month  of  April  last.  She  had  never  been  in  robust  health, 
and  during  the  last  two  years  gradually  lost  the  power  over  her  arms 
and  legs,  to  such  an  extent  that  she  was  not  able  to  walk  at  all,  even 
when  supported,  and  had  to  be  carried  upstairs  to  her  room  by  two 
nurses.  She  was  entirely  incapacitated  from  doing  any  work  what- 
ever. She  first  menstruated  at  the  age  of  fourteen,  but  has  always 
been  vtxy  irregular,  and  generally  has  suffered  from  amenorrhoea. 
Eight  months  ago  the  menses  ceased  altogether,  and  from  that  time 
she  became  nearly  idiotic.  She  has  had  hysterical  mania,  during 
which  time,  for  a  week,  she  screamed  almost  continuously,  according 
to  her  brother's  account.  Her  feet  and  hands  were  cold  upon  ad- 
mission;  there  was  considerable  dilatation  of  both  pupils;  she  spoke 
only  in  the  faintest  whisper,  and  even  then  very  rarely.  She  had 
no  appetite,  and  the  bowels  were  obstinately  constipated.  She  had 
been  under  medical  treatment  for  a  long  time,  but  without  any 
benefit.  She  had  some  retroversion  of  the  uterus  to  left  side,  and 
some  vaginitis.  Examination  by  the  aesthesiometer  revealed  that  she 
could  not  distinguish  whether  she  was  touched  by  one  point  or  two. 
The  muscles  were  atrophied  all  over  the  body,  the  fingers  were  flexed 
in  the  palms,  and  the  patient  made  no  attempt  to  attend  to  the 
organic  functions  of  the  body.  I  prescribed  a  pill  of  aloes,  iron, 
quinine,  arsenic,  and  strychnia,  to  act  on  the  bowels  and  as  a  tonic, 
and  fed  her  with  milk  and  beef  essence,  made  in  the  house,  until  the 
constipation  was  relieved.  I  used  three  times  a  week  the  continuous 
galvanic  current  from  thirty-two  cells  of  a  freshly-charged  battery, 


HYSTERIA.  387 

the  negative  pole  to  the  neck,  and  the  positive  to  the  sacrum,  for 
fifteen  minutes.  The  sensation  of  burning  was  evidently  well  marked, 
as  the  patient  drew  herself  away  and  tried  to  evade  the  contact  of 
the  electrode.  The  muscles  of  the  calves  of  the  legs  were  faradized 
daily  for  ten  minutes.  The  pill,  before  mentioned,  was  kept  up  thrice 
daily,  and  massage  diligently  and  faithfully  applied  by  a  good  nurse. ' 
After  four  weeks'  treatment,  she  was  so  much  improved  that  she 
could  walk  about  her  floor,  and  now  walks,  August  ist,  all  over  the 
house.  The  amenorrhoea  yielded  to  the  exhibition  of  capsules  of 
apiol.  She  was  very  listless,  had  a  vacant  look,  and  was  nearly,  as 
I  have  said,  idiotic.  She  regained  her  speech,  and  was  discharged 
in  perfect  health,  the  muscular  and  nervous  systems  having  become 
perfectly  restrung. 

Ti^eatmcnt. — The  treatment  of  aggravated  hysteria  is  almost  im- 
possible in  the  home  of  the  patient  and  in  the  midst  of  the  usual 
surroundings,  as  the  moral  and  bodily  constitution  rapidly  deterio- 
rates under  the  influence  of  the  pity,  sympathy,  and  over-attention 
which  hysterical  patients  live  for,  and  which  they  are  constantly 
laying  plans  to  attract  from  their  friends.  There  is  no  radical  cure 
for  hysteria  but  judicious  firmness  of  management,  combined  with 
kindness  and  friendliness  of  manner  on  the  part  of  the  physician. 
This  is  much  more  easily  accomplished  by  a  change  of  scene  and 
surroundings.  In  addition  to  improving  the  general  health  and 
bringing  up  the  general  nervous  tone,  regulating  the  menstrual 
function,  relieving  ansemia  and  constipation,  and  local  symptoms  of 
hysteria,  the  patient  should  be  made  to  take  an  interest  and  pleasure 
in  some  occupation,  intellectual  recreation,  or  study.  We  must  en- 
deavor to  remove  the  mental  or  emotional  cause  of  the  disease,  and 
particular  attention  must  be  paid  to  diet,  rest,  exercise,  and  recrea- 
tion. The  class  of  patients  whom  we,  as  physicians,  principally 
see,  are  women,  who,  from  their  social  position  and  surroundings, 
have  really  no  object  in  life  but  to  amuse  themselves.  They  have, 
as  a  rule,  been  spoiled  and  petted  since  childhood,  and  as  their 
nervous  system  is  developed  far  in  excess  of  their  physique,  they 
become,  as  they  grow  up,  capricious  and  hysterical.  Their  imag- 
inary ailments  are  undoubtedly  the  cause  of  much  distress  to  them, 
for  to  a  person  with  highly  strung  nerves  a  slight  pain  seems  a 
severe  pain,  and  discomfort  is  magnified  into  pain.  One  of  my 
last  cases,  who  had  an  income  of  six  thousand  dollars,  and  who  had 
nothing  to  do,  and  who  had  consequently  become  an  aggravated 


388  PSYCHOLOGICAL    MEDICINE. 

case  of  hysteria,  would  have  been,  as  a  physician  who  was  also  a  pa- 
tient with  me,  remarked,  "  a  splendid  woman  if  she  had  to  live  on 
twenty-five  hundred  dollars  a  year."  It  is  certainly  true  that  nothing 
to  do,  and  nothing  to  profitably  occupy  the  mind  with,  are  strong 
provocations  to  hysteria  in  a  person  predisposed  to  it.  Occasionally 
hysteria  assumes  a  grave  form  and  becomes  hysterical  mania,  a  con- 
dition requiring  great  care  and  attention.  Such  a  case  came  under 
my  care  not  long  ago.  The  patient  was  a  young  lady,  twenty-four 
years  of  age,  and  upon  her  admission  she  was  acutely  maniacal,  with 
no  appreciation  of  her  condition  or  surroundings.  She  was  a  girl 
who  had  a  highly  sensitive  nervous  organization,  and  who,  being  a 
Catholic,  had  attended  all  the  Lenten  services,  and,  after  attending 
the  "  General  Confession,"  had  arrived  at  a  state  of  emotional  frenzy 
which  passed  into  hysterical  insanity.  She  was  entirely  incoherent 
with  delusions  relating  to  religious  subjects,  and  also  relating  to  per- 
sons. The  physical  condition  was  very  fair.  She  was  given  a  warm 
bath,  followed  by  one  fluid  drachm  of  Fothergill's  solution  of  hy- 
drobromic  acid.  This  was  followed  in  four  hours  by  a  4-grain  cap- 
sule of  monobromide  of  camphor,  and  the  patient  slept  well.  For  a 
week  after  admission,  rest  in  a  darkened  room,  with  monobromide 
of  camphor  thrice  daily,  and  Fothergill's  solution,  following  the  use 
of  the  prolonged  warm  bath,  was  employed.  At  the  end  of  that 
time  the  delusions  had  disappeared,  the  mania  had  subsided,  and  the 
patient  made  her  appearance  in  the  family  circle.  Electricity,  in  the 
form  of  central  galvanization,  was  applied  daily.  Daily  exercise  was 
insisted  upon,  and  due  remedial  treatment  continued,  and  in  a  short 
time  a  perfect  recovery  took  place.  The  lady  has  since  married,  and 
has  enjoyed  perfect  health  up  to  the  present  time. 

Hysterical  patients  require  to  be  watched,  attended  to  and  uncon- 
sciously guided  away  from  self  and  into  new  grooves  of  thought, 
feeling  and  action,  at  once  interesting  to  the  mind,  while  not  fatiguing 
to  the  body  ;  and  this  can  be  done,  not  by  harshness  or  discipline, 
but  by  kindness,  firmness  and  wise  regard  to  the  feelings  of  the  pa- 
tient. We  must  supply  some  purpose  or  motive  in  life  which  can 
easily  be  done  by  studying  patients'  characters,  thus  stimulating  them 
to  make  co-operative  endeavors  for  their  own  cure,  unknown  to 
themselves.  All  this  requires  strong  will  and  great  patience  on  the 
part  of  the  physician,  but  success  is  certain  if  such  treatment  be  per- 
severed in  and  is  not  interfered  with  by  over-anxious  friends  or  relatives. 
With  regard  to  the  medicinal  treatment  to  be  pursued,  I  have  used 


HYSTERIA.  389 

with  benefit  monobromide  of  camphor,  two  or  four-grain  pill  thrice 
daily,  Fothergill's  solution  of  hydrobromic  acid,  the  chloral-phos- 
phide of  arsenic  (Routh's  formula),  the  bromide  of  lithium  and  the 
constant  current  of  electricity.  Niemeyer  said  :  "  There  is  no  doubt 
but  that  the  morbid  excitement  of  the  motor  nerves  which  gives  rise 
to  hysterical  spasms,  proceeds  from  the  spinal  marrow  and  medulla 
oblongata."  And  this  morbid  excitement  is,  in  my  experience,  very 
markedly  relieved  by  the  employment  of  the  constant  current  in  the 
manner  I  have  spoken  of.  It  is  certainly  one  of  the  most  effectual 
nervines  and  affords  radical  relief  in  most  cases,  instead  of  the  merely 
palliative  effects  obtained  from  many  drugs.  The  psychical  treat- 
ment is,  however,  of  primary  importance.  By  the  use  of  the  gal- 
vanic or  constant  current  of  electricity,  we  modify  the  circulation 
and  nutrition  of  the  whole  body,  and  from  my  experience  with  it, 
I  am  more  and  more  satisfied,  as  Niemeyer  said :  "  that  in  the 
constant  current,  we  have  a  means  more  powerful  than  any  other 
of  modifying  the  nutritive  conditions  of  parts  that  are  deeply  situated." 

When  hysteria  is  caused  by  uterine  disease  or  by  anomalies  of 
menstruation,  the  original  cause  must,  of  course,  be  removed,  if  pos- 
sible, by  appropriate  treatment.  In  several  cases  I  have  discovered 
the  existence  of  dysmenorrhoea,  which  I  have  entirely  cured  by  the 
fluid  extract  of  viburnum  prunifoHum  in  i-fluid-drachm  doses.  This 
in  some  cases  is  a  very  valuable  remedy.  In  cases  where  the  hys- 
terical state  seems  to  depend  upon  chronic  uterine  disease,  in  mar- 
ried women,  when  there  is  a  condition  of  malnutrition  and  passive 
congestion,  to  improve  the  uterine  tissues  and  to  excite  reflex  ac- 
tion, so  that  the  nerves  accompanying  the  distended  vessels  will 
cause  contraction,  and  thus  restore  the  natural  tonicity,  I  direct  the 
prolonged  application,  by  the  nurse,  of  hot-water  vaginal  injections, 
with  local  application  of  electricity  as  an  adjunct.  By -this  means  we 
are  generally  successful  in  combating  the  state  of  chronic  inflamma- 
tion that  exists  in  such  cases. 

In  conclusion  I  would  say,  study  the  uterus  and  ovaries  and  see 
that  existing  diseases,  if  there  be  any,  are  remedied.  Examine  the 
eyes,  if  you  find  head  symptoms  in  hysteria  and  neurasthenia,  and  I 
would  place  the  utmost  stress  on  the  systematic  treatment  by  rest, 
seclusion  from  society,  full  feeding,  massage  and  electricity.  This 
treatment,  if  carefully  carried  out  by  trained  nurses,  will  restore  many 
women  to  health  who  are  entirely  discouraged  by  the  failures  of  their 


390  PSYCHOLOGICAL    MEDICINE. 

physicians  to  cure  them,  and  many  of  whom  are  on  the  borderland 
of  insanity. 

Nervous  affections,  and  especially  hysterical  disorders,  are  very  con- 
tagious. The  following  interesting  case  illustrates  this  fact.  The 
inland  market-town  of  Pledrau,  in  France,  has  inhabitants  who  lead  a 
very  primitive  mode  of  life,  and  who  are  very  ignorant,  credulous  and 
simple.  Any  unusual  occurrence  is  attributed  to  an  occult  influence. 
They  are  under  the  exclusive  control  of  their  cure.  Near  this  town 
live  the  Marcet  family,  in  which  were  seven  children,  a  few  months 
ago,  said  to  be  ''possessed  by  spirits T  February  23d,  1882,  Marie 
Jean  Marcet  had  a  nervous  attack,  Vv'ith  pain  in  the  head  and  sick- 
ness, and  hysterical  paralysis,  lasting  four  days,  and  chorea-like  move- 
ments. They  soon  ceased,  and  did  not  appear  again  until  the  21st 
of  April.  On  the  22d  of  April,  the  third  child,  Pierre,  aged  ii  years, 
was  suddenly  attacked,  and  his  attack  lasted  four  hours  ;  twelve  days 
after  he  had  a  second  hysterical  fit,  and  since  then  he  has  been  very 
nervous  and  excitable,  and  very  irritable.  On  the  23d  of  April, -the 
second  daughter,  aged  13  years,  had  a  nervous  attack  resembling  in 
all  points  that  of  her  sister.  Next  day,  that  is  the  24th  of  April,  the 
fifth  child,  Anne  Marie,  aged  6  years,  had  an  attack  of  unconscious- 
ness. On  the  28th,  still  another  of  4  years  showed  hysterical  symp- 
toms, and  finally  another  child  suffered  from  unmistakable  hysteria. 
This  is  a  very  remarkable  instance  of  the  contagiousness  of  nervous 
affections,  as  this  hysteria  major  evidently  appeared  in  this  family  as 
a  small  epidemic. 

Dr.  Samuel  "VVilks,  Physician  to  Guy's  Hospital,  has  said : 

In  women  at  the  climacteric  period  we  see  the  effect  of  lowering  of  the  nervous  influ- 
ence in  the  fluttering  of  the  heart,  and  the  sickness,  sighings,  headache,  etc.  Probably 
no  other  invalids  really  feel  so  ill  as  these  patients ;  the  whole  bodily  functions  are  dis- 
turbed, and  consequently  a  depression  is  experienced  far  exceeding  that  which  accompa- 
nies any  real  organic  disease.  Such  patients  describe  their  feelings  with  the  utmost 
despondency;  they  experience  successive  changes  of  temperature,  which  they  style 
flushes  of  heat;  they  complain  of  anorexia,  of  flatulence,  and  of  irritation  of  the  bowels, 
uterus,  or  urinary  organs.  In  fact,  there  is  not  a  single  viscus  which  does  not  suffer  dis- 
turbance, so  that  every  disease  in  the  nosology  may,  in  turn,  be  supposed  to  be  present. 
Why  one  organ  should  suffer  more  than  another,  or  why  a  morbid  sensation  should  be 
experienced  in  this  part  of  the  body  rather  than  in  that,  is  probably  to  be  explained  by 
the  anatomical  distribution  of  the  nerves ;  but  we  certainly  find  that,  probably  owing  to 
the  large  supply  of  the  sympathetic  nerve  in  the  abdomen,  greater  depression  is  expe- 
rienced in  abdominal  than  in  other  forms  of  disease,  and  that  in  all  low  conditions  of  the 
nervous  system  morbid  sensations  are  very  often  referred  to  this  region  of  the  body. 
Thus,  we  cannot  but  contrast  the  cheerful  disposition  of  the  phthisical  patient,  when 
on  the  brink  of  the  grave,  with  the  depression  observed  in  one  who  has  but  a  temporary 


HYSTERIA.  391 

disturbance  of  his  stomach,  liver,  or  bowels;  and  another  indication  of  the  same  fact  is 
the  placing  of  the  emotions  in  these  parts,  as  expressed  by  the  term  "  boM-els  of  com- 
passion." 

Under  the  most  varied  conditions,  both  in  men  and  women,  when  life  is  low,  a  number 
of  morbid  sensations  arise.  In  a  state  of  health  man  should  be  as  happy  and  joyous  as 
the  lark  flying  in  the  heavens;  he  should  have  a  keen  sense  of  animal  enjoyment,  and  he 
should  feel  nothing  of  the  working  of  the  machinery  within  him ;  but  when  his  nervous 
system  is  depraved  he  becomes  conscious  of  all  these  movements,  he  feels  his  heart  beat, 
his  head  throb,  and  his  back  ache.  A  study  of  these  nervous  symptoms  would  probably 
S'how  in  what  order  they  appear;  I  think  that  they  commence,  especially  in  women,  with 
a  pain  in  the  left  side,  and  that  this  is  followed  by  pains  on  the  top  of  the  head,  and  in 
the  back,  at  the  epigastrium,  over  the  collar-bones,  etc.  I  feel  uncertain  whether  these 
pains  are  altogether  subjective  or  due  to  some  prior  alteration  of  function  in  the  parts 
whence  the  pain  proceeds.  This  question,  however,  is  one  of  very  great  importance  in 
practice  ;  for  we  often  find  that,  by  attempting  to  relieve  symptoms,  we  gain  no  headway 
towards  overcoming  disease,  whilst  by  altogether  disregarding  them,  and  having  re- 
course to  a  general  tonic  plan  of  treatment,  we  can  ensure  a  cure  within  a  certain  period. 
At  the  same  time  it  cannot  be  denied  that  the  application  of  remedies  to  the  spot  to 
which  the  morbid  sensation  is  attributed  is  frequently  attended  with  success.  Thus,  plas- 
ters to  the  side,  sedatives  to  the  stomach,  etc.,  do  give  relief.  Relieving  the  local  symp- 
toms in  this  way  is  not,  however,  incompatible  with  a  treatment  directed  to  the  restora- 
tion of  the  nerve  centres  themselves. 

In  practice,  we  have  almost  every  hour  of  the  day  to  endeavor  to  discover  whether 
morbid  sensations  in  and  disturbances  of  the  viscera  are  due  to  anorganic  cause  or  to  the 
mere  failure  of  the  regulating  power  of  the  nerves  ;  that  is,  whether  the  disease  is  organic 
or  functional.  In  such  cases  the  diagnosis  is  doubly  difficult  in  females,  because  symp- 
toms resembling  those  of  almost  every  form  of  disease  may  be  produced  by  their  more 
delicate  nervous  organization. 

We  can  imagine,  by  way  of  analogy,  that  in  the  case  of  a  steam-engine  working  irregu- 
larly we  might  for  a  time  be  at  a  loss  to  discover  whether  the  derangement  was  owing  to 
some  material  deficiency  in  the  valves  or  joints,  or  whether  it  was  due  simply  to  an  irregu- 
lar supply  of  steam.  Or,  again,  we  can  picture  to  ourselves  a  clock  perfect  in  all  its  parts 
moving  too  slowly,  from  the  simple  fact  of  the  weight  having  nearly  run  down. 

In  the  cerebro-spinal  system,  again,  an  exaltation  or  a  depression  of  function  is  con- 
stantly witnessed.  Such  conditions  are  observed  in  chorea,  in  hysteria,  and  in  various 
passions  of  the  mind.  Miiller  speaks  of  the  nervous  principle  in  the  medulla  oblongata 
.as  being  in  a  state  of  tension  and  always  ready  to  act,  and  he  says  that  the  slightest 
change  in  its  condition  excites  a  discharge  of  nervous  influence,  as  is  manifested  in 
laughing,  sneezing,  etc.  Thus  every  mental  impulse  to  motion  disturbs  the  balance  of 
this  tension  and  causes  a  discharge  of  nervous  influence  in  a  determinate  direction.  He 
also  compares  the  nervous  system  to  a  musical  organ,  with  its  bellows  charged  and  ready 
to  force  a  stream  of  air  in  any  direction,  according  to  the  particular  key  that  may  be 
touched.  Using  this  illustration,  we  may  imagine  the  air  either  to  rush  out  with  a  scream, 
or  to  be  hastily  allowed  to  pass  off  by  the  larger  tubes,  or  to  be  diffused  melodiously 
through  a  series  of  musical  pipes.  In  a  similar  way  the  superfluous  nerve-force  may  dis- 
play its  operations  in  various  ways,  according  to  the  sex,  age,  and  temperament  of  the 
patient.  For  example,  I  have  seen  the  same  cause  produce  hysterics  in  a  mother  and 
chorea  in  her  child,  the  one  disease  being  almost  peculiar  to  the  adult  period  of  life, 
the  other  to  childhood.  The  same  fright  which  excited  so  great  an  amount  of  nerve- 
force  in  the  mother  as  to    cause  the   explosion  known  as  hysterics  operated  on  the 


392  PSYCHOLOGICAL    MEDICINE. 

child  in  a  slower  manner,  and  gave  rise  to  the  less  violent  action  known  as  chorea. 
The  spinal  system  was  excited  to  over-action  by  the  cineritious  substance  above,  which 
had  been  unduly  stimulated  by  a  mental  shock,  and  remained  temporarily  impaired  until 
the  disease  was  cured.  The  explosion  of  nerve-force  by  an  hystei-ical  attack  acts  as  a 
kind  of  safety-valve,  protecting  the  internal  machinery  from  danger ;  and  although  all 
are  not  alike  impressionable,  there  is  scarcely  an  individual  who  may  not  be  in  need  of 
it  when  acted  on  by  a  sufficiently  powerful  stimulus.  Even  in  the  strong-minded  Napo- 
leon a  fit  is  said  to  have  been  excited  by  passion.  More  commonly,  however,  relief  to 
an  over-excited  nervous  system  is  afforded  by  laughing  or  crying.  Thus,  as  Byron  ob- 
serves, the  power  which  women  possess,  as  compared  with  men,  of  being  able  to  pour 
their  troubles  into  their  pocket-handkerchiefs,  is  no  doubt  often  very  beneficial  to  them,  so 
far  as  their  health  is  concerned.  A  woman  who  is  excited,  if  she  do  not  go  into  hysterics 
or  have  a  good  cry,  often  allows  the  redundant  nerve-force  to  escape  through  that  unruly 
member  the  tongue,  and  thus  an  extreme  volubility  of  utterance  perhaps  saves  her  from 
further  unpleasantness.  Of  course,  tlie  talk  which  flows  from  her  lips  is  altogether  dif- 
ferent from  the  result  of  an  intellectual  process ;  and  thus  it  is  still  true  now,  as  it  was  in 
ancient  times,  that  "anger  is  a  short  madness."  In  Switzerland,  last  summer,  I  met  an 
Irish  gentleman,  who  told  me  that  he  could  make  his  wants  known  without  a  knowledge 
of  the  language,  but  that  when  he  was  irritated  and  wanted  to  swear  he  would  sometimes 
give  all  he  possessed  to  understand  German.  In  other  cases,  again,  the  superfluous  force 
escapes  by  the  limbs ;  thus  an  angry  person  slams  the  door,  or  destroys  even  her  own 
property.  A  man  of  better  sense,  when  vexed,  takes  a  walk,  and  thus  gets  rid  of  his 
extra  nerve-force ;  or,  if  the  irritation  and  its  results  are  more  chronic,  sits  down,  takes 
up  his  pen,  and  by  publishing  "  the  whole  correspondence  "  eases  his  mind. —  Guys  Hos- 
pital Repoi-ts,  vol.  xii.,  1866,  p.  247. 

Dr.  F.  C.  Skey,  Esq.,  F.R.S.,  Consulting  Surgeon  to  St.  Bartholo- 
mew's Hospital,  has  said  in  respect  to  hysteria: 

In  the  whole  range  of  practical  surgery  there  is,  perhaps,  no  one  subject  that  claims 
your  earnest  study  more  important  than  that  which  I  have  selected  for  this  and  the  fol- 
lowing lectures.  It  is  not  a  question  of  diagnosis  between  two  diseases  more  or  less 
resembling  each  other.  It  is  a  question  of  disease  or  no  disease,  of  reality  or  imitation, 
of  true  or  false — of  whether  your  purgatives,  your  bleedings,  sweatings,  irritants  and 
counter-irritants,  and  your  whole  battery  of  antiphlogistics,  shall  be  launched  against  a 
true  disease  in  the  flesh,  or  its  ghost — whether  you  are  to  contend  with  a  reality  or  a 
shadow.  This  absence  of  discrimination  between  two  conditions  of  disease  and  no  dis- 
ease is  painfully  frequent  among  medical  men,  especially  among  those  to  whose  charge 
is  assigned  the  care  of  local  and  surgical  diseases.  "  In  one  shape  or  another,"  ob- 
serves the  greatest  of  modern  surgeons,  "  you  will  meet  with  them  at  every  turn  of  your 
future  practice."  It  may  be  asserted  with  truth  that  every  part  of  the  human  body  sup- 
plied with  nerves,  be  they  cerebral,  spinal,  or  ganglionic,  may  become  under  provoca- 
tion the  seat  of  local  symptoms  so  closely  resembling  those  of  the  real  disease  to  which 
that  part  of  the  body  is  liable,  as  to  appear  identical  with  it,  and  the  resemblance  to 
which  is  so  perfect  as  to  deceive  the  best  of  us.  They  are  not  cases  of  occasional  or 
rare  occurrence.  They  come  before  us  in  the  daily  and  hourly  walks  of  professional 
life.  They  monopolize  a  share,  and  not  a  small  one,  of  all  cases  under  treatment, 
whether  medical  or  surgical,  but  the  latter  predominate.  The  closer  you  scrutinize 
them,  the  more  penetrating  your  inquiry — looking  into,  and  not  at  them — the  more  per- 
fect will  be  your  diagnosis,  and  the  more  you  will  be  astonished  that  a  form  of  disease 


HYSTERIA.  393 

so  remarkable  and  so  common  should  have  hitherto  occupied  so  little  of  your  thoughts. 
It  is  well  to  call  your  attention  to  tliis  description  of  malady  at  the  early  stage  of  your 
career.  Many  men  pass  through  life,  engaged  in  active  warfare  against  disease,  on 
whose  convictions  this  variety  has  scarcely  dawned.  And  this  is  a  truly  remarkable 
fact,  which  owes  its  existence  to  the  predominating  influence  which  the  heart  and  the 
arterial  system  exercise  over  the  judgment  of  the  profession  at  the  expense  of  a  system 
yet  higher  in  the  scale  of  organization,  more  sensitive,  and  more  liable  to  morbid  im- 
pressions'— -viz.,  the  cerebro-spinal  nervous  system. 

"Whenever  a  new  case  of  disease  presents  itself  to  us  we  jump  to  the  old  doctrines  of 
inflammation,  we  talk  of  congestion,  and  of  capillary  action,  and  of  deposits  of  lymph, 
and  we  refer  the  attendant  pain  and  heat  to  an  inflammatory  condition,  of  which  the  local 
nervous  derangement  is  an  ordinary  symptom.  We  should  endeavor  to  assign  to  each 
system  its  proper  place  in  the  pathological  scale  and  to  discriminate  more  accurately 
than  is  generally  done  the  indications  which  belong  to  the  morbid  condition  of  each, 
whether  existing  in  combination  or  separately ;  for  be  assured  they  do  exist,  both  sepa- 
rately and  in  combination  with  each  other.  You  may  have  varieties  of  inflammation  in 
which  the  local  pain  is  trivial  when  compared  with  its  severity  in  other  cases,  while,  on 
the  other  hand,  examples  daily  occur  in  which  local  as  well  as  general  derangement  of 
the  nerves,  whether  of  the  part  or  of  the  whole  body,  exists  as  a  condition  entirely  inde- 
pendent of  the  vascular  system.  Nor  is  this  derangement  confined  to  the  sensory  nerves. 
If  we  have  local  pain  as  the  indication  of  excessive  activity  of  the  nerves  of  sensation,  we 
have  spasm  and  convulsions,  indicating  derangement  of  the  nerves  of  motion,  each  of 
which,  or  both,  may  prevail  without  heat,  or  redness,  or  swelling.  We  daily  see  severe 
forms  of  nervous  exacerbation  without  the  slightest  corresponding  increase  of  action  in 
the  vascular  system.  There  is  this  important  difference  between  the  morbid  states  of  the 
vascular  and  nervous  systems,  that,  while  local  inflammations  are  dependent  on  local 
causes,  aggravated  only  by  the  impaired  condition  of  the  general  health,  local  nervous 
diseases  for  the  most  part  oi-iginate  in  the  centres  of  nervous  power,  the  effects  of  which 
are  exhibited  in  remote  parts  of  the  body — it  may  be  in  a  pain  localized  in  a  given  spot, 
whether  on  the  surface  or  in  deeply-seated  parts  which,  to  our  senses,  holds  no  especial 
relation  to  its  nervous  centre ;  it  may  be  in  a  temporary,  or  spasmodic,  or  permanent 
contraction  of  the  voluntary  muscles  bending  the  joints  of  the  extremities  in  permanent 
flexion,  or  obliquely  drawing  the  head  upon  the  trunk,  or  involving  the  whole  motor  sys- 
tem, as  in  tetanus.  No  known  nerve  that  conveys  sensibility  from  its  centre  to  its  per- 
iphery, no  motor  nerve  that  carries  volition  from  the  brain  or  spinal  cord  to  a  voluntary 
muscle,  is  exempt  from  this  morbid  tendency. 

The  vascular  system,  consisting  of  arteries,  capillaries,  and  veins,  has  its  own  special 
diseases,  peculiar  to  the  structures  engaged  in  the  circulation  of  the  blood.  The  attend- 
ant symptoms  are  heat,  redness,  pain,  and  swelling,  the  latter  symptom  being  due  to  a 
sepai-ation  from  the  capillary  system  of  some  constituents  of  the  blood,  whether  in  a  fluid 
or  solid  form,  while  the  morbid  condition  of  the  nerves  and  the  structures  in  which  they 
originate  are  characterized  by  simple  aggravation  or  excess  of  the  functions  of  the  nerves 
affected,  the  natural  sensibility  of  the  sensory  nerves  running  into  pain,  and  the  moving 
power  of  motor  nerves  into  convulsions,  or  spasm,  or  permanent  contraction.  In  diseases 
of  the  vascular  system  we  have  changes  of  structure ;  in  the  latter,  not.  It  is  necessary 
to  make  very  clear  the  line  which  separates  the  two  classes  of  disease,  lest  we  fall  into 
the  common  error  of  applying  to  both  the  remedial  agents  which  are  applicable  to  one 
only.  The  diseases  originating  in  or  involving  the  vascular  system  we  treat  locally  by 
various  agents — leeches,  blisters,  etc. ;  in  diseases  confined  to  the  nervous  system  these 
local  remedies  are  useless  and  even  injurious,  and  we  treat  them  through  the  constitution. 


394  PSYCHOLOGICAL    MEDICINE. 

In  cases  of  tic  do  we  derive  benefit  from  leeches,  or  blisters,  or  from  other  forms  of  deple- 
tive agents  ?     Assuredly  not. 

Now  the  disease  which  forms  the  subject  we  have  to  consider  belongs  to  the  nervous 
and  not  to  the  vascular  class,  and  I  select  from  this  variety  that  occasionally  known 
under  the  term  "  hysteria,"  than  which  no  name  can  be  more  inappropriate  or  objection- 
able. It  may  well  be  doubted  whether,  except  under  very  occasional  circumstances, 
such  a  relation  holds  between  the  womb  and  this  remarkable  train  of  symptoms  as  to  jus- 
tify the  employment  of  the  term  hysteria.  In  the  large  majority  of  cases  there  is  no  con- 
nection between  them  beyond  that  which  the  disease  holds  with  the  other  organs  of  the 
body.  In  the  name  of  a  disease  we  are  supposed  to  recognize  its  form  and  nature, 
whereas  the  term  I  have  quoted  conveys  to  the  mind  no  distinct  idea  of  either  one  or  the 
other.  And  there  is  a  positive  objection  to  the  resort  to  it  in  the  fact  that  the  word  car- 
ries with  it  the  association  of  a  malady  of  small  and  insignificant  dimensions,  while  the 
malady  itself  is  of  great  magnitude.  We  associate  with  it  the  idea  of  "  hysterics  "  and 
"  vapors,"  as  they  were  formerly  called.  I  wish  to  raise  your  attention  to  the  level  of  a 
great  malady,  and  not  of  a  trivial  derangement  of  the  hour.  I  remember  a  law  case  in 
which  the  counsel  challenged  a  medical  witness  as  to  the  name  of  the  disease,  and  he 
replied,  hysteria.  "Hysteria!"  said  the  learned  counsel,  addressing  the  jury,  "  we  all 
knov\'  what  hysteria  means.  My  client  has  come  into  court  to  obtain  compensation  from 
a  jury  of  his  country  for  a  permanent  injury  by  which  all  his  prospects  are  blighted,  etc., 
etc.,  and  the  gentleman  in  the  witness-box,  with  no  sympathy  for  his  misfortune,  pro- 
claims the  disease  to  be  a  case  of  trumpery  hysterics  !"  and  the  jury,  with  rod  in  hand, 
let  it  fall  heavily  on  the  defendant's  back.  But  there  is  a  more  solid  objection  than  these, 
viz.,  that  it  is  founded  on  a  false  pathology,  in  the  employment  of  a  term  that  conveys 
an  impression  of  its  source  and  nature  founded  in  error.  The  disease  consists  in  the 
local  evidence  of  some  irritation  or  derangement  of  one  or  the  other  of  the  nervous  cen- 
tres of  the  body,  viz.,  the  brain  or  the  spinal  cord — at  least,  such  is  the  received  pathol- 
ogy. But  the  subject  is  a  very  obscure  one.  We  have  no  very  definite  idea  of  what  we 
mean  by  "  irritation."  We  all  employ  it,  and  so  general  is  its  use  that  I  don't  know  how 
we  can  get  on  without  it.  "  Irritation  of  the  nervous  centres"  is  a  useful  and  not  ill- 
sounding  phrase,  though  somewhat  mysterious,  but  it  is  no  reflection  on  medical  science 
that  we  can't  explain  all  the  phenomena  of  life,  and  as  the  term  is  somewhat  wide  in  its  ap- 
plication and  does  not  commit  its  employer  to  any  very  defined  opinion  on  obscure  mat- 
ters, on  which  it  is  verj'  difficult  to  form  any  opinion  at  all,  I  pi-esume  we  shall  retain  it. 
One  good  reason  that  may  be  assigned  for  the  persistent  employment  of  the  term  hysteria 
— a  term  we  all  know  to  be  objectionable — is  the  difficulty  of  finding  a  substitute  for  it. 
We  call  the  disease  "local  nervous  irritation."  It  is  "  exalted  nervous  sensibility,"  but 
in  naming  a  disease  so  definite  as  this  we  require  a  term  equally  pointed  and  definite  with 
the  thing  itself.  That  we  have  not  got.  Sir  B.  Brodie  says  :  "  I  employ  the  term  hys- 
teria because  it  is  in  common  use,  but  the  etymology  is  calculated  to  lead  to  great  misap- 
prehension." 

Failing  the  name,  let  us  look  at  the  thing,  and  if  it  be  so  critical  as  I  have  assured 
you,  let  us  attach  to  it  the  great  impoitance  its  frequency  and  its  magnitude  demand. 

It  may  be  asserted  with  truth  that  every  part  of  the  body  may  become,  under  provoca- 
tion, the  seat  of  an  apparent  disease  that  in  reality  does  not  exist ;  that  it  may,  and  often 
does,  assume  all  the  attributes  of  reality  with  an  exactness  of  imitation  which  nothing 
short  of  careful  and  accurate  diagnosis  can  distinguish  from  the  real  disease.  You  think 
this  is  impossible.  Surely  you  know  a  diseased  knee-joint  when  you  see  it.  You  find 
severe  pain,  aggravated  by  the  slightest  movement.  The  temperature  of  the  joint  may 
be  raised,  and  it  is  slightly  swelled.     You  leech,  you  blister,  you  employ  an  iodine  lini- 


HYSTERIA.  395 

ment  (few  cases  escape  it),  you  may  even  resort  to  issues,  but  the  evil  remains  in  spite  of 
all  your  remedies,  which  have  been  applied  to  the  wrong  "system."  It  is  the  nervous, 
not  the  vascular  that  is  involved,  but  the  nervous  has  imitated  the  vascular,  and  deluded 
you,  and  led  to  the  employment  of  false  remedies,  which  have  failed  to  reduce  the  pain 
or  give  mobility  to  the  joint,  and  the  general  influence  of  which  on  the  health  of  the 
patient  cannot  be  said  to  have  proved  eminently  serviceable. 

The  case,  on  more  perfect  investigation,  proves  to  be  one  of  local  nervous  irritation  or 
hysteria.  You  think  you  will  not  be  again  deceived,  but  you  are  mistaken.  A  single 
error,  corrected  by  the  experience  of  another,  will  not  teach  you  hysteria.  You  are  con- 
sulted by  a  lady  in  reference  to  a  daughter  of  i8  or  20  years  of  age,  who  has  exhibited 
failing  health  for  some  time,  and  now  complains  of  her  inability  to  walk  in  consequence 
of  a  pain  in  her  back.  You  examine  her,  and  discover  that  she  suffers  extremely  on  pres- 
sure over  two  or  three  of  the  lower  dorsal  vertebrse  or  on  any  other  of  the  twenty-four. 
You  repeat  the  examination  with  the  same  result,  and  you  make  a  report  to  the  mother 
that  her  daughter  has  "  spinal  disease."  The  result  of  your  opinion  is  two  or  more  years' 
confinement  to  her  couch,  coupled  with  the  usual  allowance  of  restricted  diet,  alterative 
and  other  depletive  medicines,  leeches,  blisters,  and  issues.  Suppose  these  structures 
which  you  have  declared  to  be  the  seat  of  organic  disease  to  be  examined  under  a  micro- 
scope, what  would  you  discover  ?  Nothing.  There  is  no  disease  whatever.  As  the 
nature  of  this  malady  dawns  upon  you,  now  awakening  to  a  conviction  of  its  frequency, 
you  resolve  to  be  more  wary  in  your  future  diagnosis.  You  are  now  consulted  by  an- 
other young  female  patient  on  account  of  a  tendency  in  one  or  more  fingers  to  close  in 
flexion.  In  the  attempt  to  straighten  them  you  cause  intense  pain,  and,  if  persisted  in, 
the  consequences  may  be  serious.  Your  patient  appears  in  fair  average  health,  and  all 
her  functions  are  regular  and  healthy,  while  the  hand,  for  all  ordinary  purposes,  is  use- 
less. Under  ihe  idea  that  she  may  have  some  chronic  inflammation  of  the  theca  or  of  the 
palmar  fascia,  you  treat  it  with  the  usual  remedies.  But  your  remedies  produce  no  im- 
pression on  the  finger,  which  continues  obstinately  flexed  as  before.  You  adopt  another 
principle  of  treatment,  founded  upon  a  more  correct  diagnosis,  and  your  patient  recovers. 
These  cases  sound  strange  to  your  limited  experience.  You  think  they  are  rare,  and 
brought  forward  from  a  distance  and  with  an  effort.  By  no  means.  They  are  cases  of 
daily  occurrence.  If  you  could  suddenly  throw  off  that  nebulous  vision  of  vascular  dis- 
ease which  years  of  bad  pathology  have  impressed  upon  your  judgment,  you  would  see 
them  in  their  true  light.  You  may  deem  them  to  be  exceptional.  I  assure  you  they  con- 
stitute the  rule  of  disease,  and  not  the  exception.  Real  disease  is  the  exception.  Speak- 
ing of  one  variety,  and  they  have  all  characters  in  common.  Sir  B.  Brodie,  a  man  who 
rarely  committed  an  error  in  diagnosis,  says  :  "  I  do  not  hesitate  to  declare  that,  among 
the  higher  classes  of  society,  at  least  four-fifths  of  the  female  patients  wlio  are  commonly 
supposed  to  labor  under  diseases  of  the  joints  labor  under  hysteria,  and  nothing  else." 
I  would  venture  to  enlarge  this  statement  as  regards  the  "  upper  classes  "  by  including  a 
large  proportion  of  the  lower,  for  much  of  my  own  experience  of  hysteria  has  been  ob- 
tained from  the  wards  of  St.  Bartholomew's  Hospital,  and  in  reference  to  spinal  affections 
in  young  persons,  I  unhesitatingly  assert  that  real  disease  is  not  found  in  a  greater  pro- 
portion than  one  case  in  twenty,  and  even  this  is  a  liberal  allotment.  Have  you  never 
experienced  the  difficulty  of  discovering  an  object  floating  in  the  air,  such  as  a  bird  sing- 
ing overhead  or  an  early  star  in  the  evening  ?  When  once  the  object  becomes  visible  the 
eye  is  readily  adjusted  to  it,  and  when  you  look  again  in  the  right  direction  it  is  the  first 
object  that  strikes  the  eye. 

And  so  with  this  class  of  diseases.  They  are  not  seen,  because  they  are  not  looked 
for.     If  you  will   so  focus  your  mental  vision,  and  endeavor  to   distinguish  the  minute 


396  PSYCHOLOGICAL    MEDICINE. 

texture  of  your  cases,  and  look  into  and  not  at  them,  you  will  acknowledge  the  truth  of 
the  description,  and  you  will  adopt  a  sound  principle  of  treatment  that,  meets  disease 
face  to  face  with  a  direct  instead  of  an  oblique  force,  which  far  too  generally  claims  the 
credit  of  a  success  for  which  nature  alone  is  responsible. 

I  have  selected  above  three  varieties  of  this  local  hysteric  affection.  Let  us  consider 
them  a  little  more  in  detail,  with  a  vaew  to  detect  the  fallacy  which  classes  them  under 
diseases  of  the  first  or  vascular  division,  by  which  I  mean  an  abnormal  condition  of  the 
bloodvessels  leading  to  changes  of  structure  or  altered  relations,  whether  by  suppuration 
or  ulceration,  or  fibrinous  deposit,  or  local  death  of  the  tissues  involved.  In  the  first 
case  the  knee  is  the  seat  of  pain.  The  subject  is  a  j'oung  female.  What  evidence  do 
we  commonly  look  for  when  the  joint  is  really  diseased?  We  look  first  for  a  cause. 
Diseased  joints  don't  occur  without  a  palpable  one,  and  particularly  in  young  persons. 
There  has  been  no  violence,  no  fall  or  blow,  to  which  to  attribute  it.  Had  there  been, 
the  nature  of  the  disease  is  obvious  enough.  There  is  no  considerable  increase  of  heat, 
and,  if  inflammation  is  present,  perceptible  increase  of  heat  is  constant.  There  is  no  effu- 
sion into  the  joint ;  the  fonn  of  the  articulation  is  unchanged.  .  The  pain  and  the  immo- 
bility or  stiffness  of  the  joint  remain,  notwithstanding  your  remedies.  Local  depletion 
relieves  the  pain  of  inflammation,  but  not  of  hysteria.  But  }'ou  persist  in  your  principle, 
and  the  depletive  principle  is  continued,  and  thus  months  elapse — yes,  even  years.  I 
was  once  told  by  a  young  lad)'  that  she  had  applied  twenty-seven  blisters  to  her  knee- 
joint,  from  which  she  could  not  say  she  had  derived  any  benefit.  Now,  it  ought  to  be 
obvious  that  if  a  painful  joint,  occurring  in  a  young  female  without  local  cause,  is  un- 
altered in  form  or  size,  and  is  free  from  heat  or  redness,  and  that  the  chief  and  almost 
the  only  symptom,  that  of  pain,  varies  in  degree  at  different  times  and  is  fluctuating  in 
character,  the  disease  is  not  of  the  inflammatoiy  class,  and  if  not,  it  must  be  nervous, 
and  you  cannot  cure  pain  with  leeches.  You  know  that  pain  alone,  which  consists  in 
an  exalted  nervous  sensibility,  does  not  constitute  what  we  strictly  understand  by  the 
term  disease,  although  we  apply  it  generally  to  any  deviation  from  health,  whether  local 
or  constitutional.  At  length  the  truth  is  brought  home  to  you.  You  change  j-our  treat- 
ment by  the  substitution  of  local  sedatives  and  general  tonics,  and  )'our  patient  moves 
forward  in  the  direction  of  recoveiy. 

Take  the  second  case.  You  have  declared  your  opinion  that  this  girl  is  the  subject  of 
disease  of  the  spine  upon  the  evidence  of  local  pain  pi'oduced  by  pressure  of  the  fingers 
on  the  spinous  processes  of  the  vertebra.  It  has  escaped  your  observation  that  this  pain 
is  equally  severe,  whether  pressure  is  slight  or  not,  that,  in  fact,  the  degree  of  pain  in- 
dicated by  either  writhing  or  exclamation  holds  no  relation  to  the  force  of  the  pressure 
made.  The  slightest  touch  creates  as  much  suffering  as  the  greatest  pressure  of  the 
hand,  and  often  more.  It  is  on  this  evidence  alone  you  have  founded  your  opinion  of 
disease  of  the  bony  structure  of  the  spinal  column.  It  is  on  this  evidence  you 
have  consigned  this  young  lady  to  two  years'  confinement  to  her  couch,  to  the  loss  of 
education,  to  restricted  social  and  domestic  intercourse  with  her  family  and  friends,  and 
to  much  moral  and  phj'sical  suffering.  Now,  when  you  talk  of  disease  of  the  spine, 
what  do  you  mean?  ^^Tiat  structure  is  diseased,  and  what  form  of  disease  is  present? 
Is  it  seated  in  the  body,  or  in  the  processes  of  the  vertebrae,  or  in  the  entire  bone  ?  And 
what  description  of  disease  has  invaded  the  particular  vertebra  of  the  twenty-four  ?  Is 
it  inflammation,  or  caries,  or  necrosis  ?  Caries,  you  will  say,  and  you  select  this  fomi, 
because,  and  only  because,  you  know  the  spinal  column  is  the  subject  of  carious  disease 
under  conditions  favoring  it.  But  there  is  this  remarkable  feature  in  carious  disease  of 
bone  well  worthj^  of  notice — viz.,  that  it  is  almost  destitute  of  pain,  that  there  exists  no 
relation  between  the  extent  of  the  disease,  which  may  be  great,  and  the  pain  attendant 


HYSTERIA. 


397 


on  it.  It  is  not  like  inflammation  of  bone,  whether  simple  or  severe,  or  necrosis.  Pre- 
suming this  statement  true,  can  you,  in  reason,  feel  satisfied  with  the  evidence  of  disease 
obtained  by  manual  pressure  ?  Then,  again,  where  is  the  disease  situated  ?  If  in  the 
body  of  the  vertebra,  is  it  not  almost  absurd  to  suppose  you  can  detect  it  by  the  slight 
pressure  of  the  finger  on  the  sunimit  of  the  spinotis  processes,  which  are  themselves  rarely 
involved. 

Fifty  or  sixty  years  ago,  a  provincial  surgeon  of  some  note  recommended  the  applica- 
tion of  a  hot  sponge  to  the  spine,  with  a  view  to  detect  disease  of  the  bodies  of  the  ver- 
tebrse.  There  was  some  excuse  for  ignorance  on  this  subject  at  that  time ;  there  is  none 
now.  Of  all  the  fallacies  that  cling  to  professional  practice,  of  all  the  false  doctrines 
which  the  pardonable  ignorance  of  a  former  generation  has  entailed  on  modern  surgery, 
none  can  surpass  that  which  affects  to  detect  carious  disease  of  the  body  of  a  vertebra  by 
drawing  the  fingers  down  the  spine.  It  is  only  not  ludicrous,  because  the  consequences 
are  so  serious  to  the  victim.  It  would  be  a  bold  assertion  that  such  morbid  changes  in 
the  spinal  column  cannot  occur ;  but  I  do  think  humanity  would  be  a  gainer,  if  all 
teachers  concurred  in  asserting  that  they  could  not,  so  rare  is  the  real  disease,  and  so 
palpable  to  the  eye  when  present.  Suppose  a  young  person,  in  moderately  good  health, 
and  occupied  in  daily  exercise,  complained  of  a  pain  in  the  condyle  of  the  femur,  wdth- 
out  any  other  indication,  should  you  be  warranted  in  declaring  she  had  serious  disease  of 
the  bone  ?  Look  to  the  functions  of  this  important  column ;  how  is  it  possible  it  can 
support  the  body  in  the  upright  posture,  if  one  or  more  of  the  component  bones  of  the 
pillar  are  destroyed  ?  And  yet  I  have  known  many  examples,  in  which  the  subject  of 
this  imaginary  disease  has  joined  a  party,  and  danced  for  the  whole  evening.  One  wonders 
that  such  a  person  did  not  drop  into  pieces.  For  myself,  I  candidly  declare  that  I  have 
scarcely  ever  seen  a  case  of  true  disease  of  this  form.  I  can  bear  testimony  to  spinal  af- 
fections and  destructions  of  bone  to  any  amount  in  psoas  or  lumbar  abscess,  or  in  angu- 
lar curvature,  or  of  damage  done  to  the  column  by  local  injury ;  but  to  these  suppositi- 
tious cases,  which  exist  only  in  the  brain  of  the  surgeon,  I  am  a  stranger,  and  if  they  exist 
otherwise  than  as  rare  examples  of  spinal  disease,  I  have  much  to  learn.  Have  you  ever 
seen  a  person  recover  from  actual  disease  of  the  spine  ?  I  do  not  mean  to  infer  that 
death  inevitably  follows,  though  that  result  is  by  no  means  uncommon ;  but  I  allude  to 
recovery  without  some  distortion,  or  some  permanent  evidence  of  past  disease.  And 
yet  you  may  be  surprised  when  I  assure  you  that  all  these  young  people  recover  sooner 
or  later — sooner,  if  the  surgeon  in  attendance  is  familiar  with  hysteric  affections  !  later, 
if  he  is  not.  Thirty  or  forty  years  since,  these  cases  were,  happily  for  our  time,  far  more 
common  than  at  present.  At  that  date,  and  for  how  many  years  anterior  I  know  not,  all 
the  seaside  towns  were  crowded  with  young  ladies,  between  seventeen  and  twenty-five 
years  of  age  and  beyond  it,  who  were  confined  to  the  horizontal  posture,  and  were 
wheeled  about  on  the  shore  in  bath-chairs,  on  the  supposition  that  they  vi^ere  the  subjects 
of  spinal  disease.  They  were  placed  under  much  medical  and  dietetic  discipline,  not  of 
the  most  invigorating  character,  and  the  large  majority  carried  a  pair  of  handsome  issues 
in  the  back  !  Brighton,  Worthing,  Hastings,  and  other  places  on  the  south  coast  were 
tenanted  largely  by  these  unfortunate  females,  to  which  a  moderate  sprinkling  of  young 
gentlemen  was  added.  What  has  become  of  all  these  cases  ?  They  appear  to  have 
vanished  just  in  proportion  as  the  eyes  of  the  surgeons  have  opened  to  the  absurdity  of 
inferring  that  pain  alone,  which  locates  itself  with  remarkable  precision  in  hysteria  on  a 
given  vertebra  can  indicate  the  presence  of  organic  disease  of  the  body  of  the  bone  with- 
out collateral  evidence  in  its  favor.  When  the  spinal  column  is  really  diseased  the  case 
is  obvious  at  a  glance ;  the  health  is  degenerate,  and  the  whole  system  proclaims  to  the 


398  PSYCHOLOGICAL    MEDICINE. 

eye  of  the  surgeon  the  presence  of  a  great  evil.  These  examples  are  but  a  miserable 
mockery  of  the  reality  and  a  fraud  on  the  judgment  of  the  ignorant. 

With  regard  to  the  third  example,  that  of  permanent  flexion  of  the  fingers,  it  is  appa- 
rently so  truly  local  an  affection  that  there  is  some  excuse  for  error,  but  only  because  hys- 
teric affections  are  not  half  studied.  When  one  or  more  of  the  fingers  is  permanently 
flexed  from  local  causes,  the  seat  of  the  disease  will  be  found  in  the  fascial  structures  of 
the  hand  or  in  the  finger  itself,  or  a  joint  may  have  been  diseased  or  dislocated  ;  but  here 
there  is  no  thickening,  nor  hardness,  or  other  morbid  change  of  structure.  The  finger  is 
simply  bent,  and  the  attempt  to  straighten  it  is  painful.  The  cause  of  this  morbid  con- 
dition of  the  flexor  muscle  is  referred  to  its  nervous  centre  placed  in  the  cervical  portion 
of  the  spinal  cord. 

It  is  not  an  easy  task  to  select  the  class  of  constitutions  most  liable  to  hysteric  diseases. 
Probably  under  certain  conditions  of  impaired  health  the  large  proportion  of  the  com- 
munity would  give  evidence  of  its  presence.  Certainly  it  is  uncommon  in  the  lower  class 
of  males,  and  among  those  who  occupy  the  beds  in  our  public  hospitals.  We  know,  on 
the  other  hand,  that  it  is  most  prevalent  in  the  young  female  members  of  the  higher  and 
middle  classes,  of  such  as  live  a  life  of  ease  and  luxury,  those  who  have  limited  responsi- 
bilities in  life,  of  no  compelled  occupation,  and  who  have  both  time  and  inclination  to 
indulge  in  the  world's  pleasures — persons  easily  excited  to  mental  emotion,  of  sensitive 
feeling,  often  delicate  and  refined.  Such  are  among  the  mental  attributes  of  hysteria. 
But  hysteric  diseases  are  not  confined  to  the  young.  I  have  seen  many  examples  in  fe- 
males of  40  to  50.  Do  not  imagine  hysteria  is  a  disease  of  persons  of  weak  minds.  It 
will  often  select  for  its  victim  a  female  member  of  a  family  exhibiting  more  than  usual 
force  and  decision  of  character,  of  strong  resolution,  fearless  of  danger,  bold  riders,  hav- 
ing plenty  of  what  is  termed  nerve.  If  you  tell  such  young  people  they  are  nervous, 
they  take  offence,  because  they  misinterpret  the  meaning  of  the  word,  and  so  may  you. 
And  they  may  well  misinterpret  it,  for,  like  the  word,  "  irritation,"  its  popular  meaning 
is  both  various  and  indefinite.  It  is  essential  that  we  attach  a  definite  idea  to  this  term 
in  its  different  applications,  and  I  must  digress  for  a  moment  to  endeavor  to  explain 
them. 

I  have  already  used  it  in  one  sense. 

1st.  The  word  nerve  is  used  to  express  the  mental  condition  of  vigor,  boldness,  and 
resolution — as  when  a  man's  nerves  are  strung  up  to  meet  danger  ;  so  ladies  are  said  to 
ride  with  more  or  less  "  nerve." 

2d.  We  employ  it  in  its  physical  sense  as  a  part  of  the  general  system  of  the  nerves  of 
the  body. 

3d.  We  have  the  terms  "  nervous  system,"  which  may  be  not  inappropriately  defined 
as  holding  the  same  relation  to  the  "  system  of  nerves  "  in  its  physical  sense  that  the 
physiology  of  a  part  holds  to  its  anatomy.  Yet  this  definition  is  imperfect,  because  the 
properties  of  the  nerves  of  the  cerebro-spinal  system,  with  the  small  exception  of  those  of 
specific  sensibility,  such  as  sight,  smell,  taste,  etc.,  begin  and  end  in  the  functions  of  mo- 
tion and  sensation.  By  the  term  "  nervous  system  "  we  understand  the  general  influence 
which  the  nerves  in  a  physical  sense  exert  on  the  constitution,  the  healthy  or  tonic  con- 
dition of  which  is  in  a  ratio  with  the  combined  force  of  the  two  systems — viz.,  the  arte- 
rial, or  circulation  of  blood,  and  the  nervous.  Health  depends  on  the  coincidence  of 
these  systems  in  perfect  action.  If  the  circulation  fails  in  power,  the  consequence  of  this 
weakness  falls  on  the  nervous  system,  which  is  dependent  on  the  circulation  for  its  health 
and  vigor.  Failing  an  adequate  supply  of  blood,  this  system  is  unstrung,  and  morbid 
sensations,  endless  in  variety,  take  the  place  of  real ;  and  of  all  consequences,  hysteria  is 
the  most  common.     In  the   defficient  supply  of  blood  to  the  brain  the  faculties  of  the 


HYSTERIA.  399 

mind  are  involved.  Confidence  of  strength  gives  place  to  fear,  mental  vigor  to  weak- 
ness and  irresolution.  Such  indications  as  are  untrue  to  the  real  character  of  the  indi- 
vidual as  the  physical  sensations  are  false  and  deceptive.  Such  is  the  nature  of  the  large 
proportion  of  cases  of  persons  who  come  into  courts  of  law  for  compensation  for  what 
are  erroneously  deemed  permanent  injury,  bringing  with  them  headaches,  spinal  pains, 
tingling  of  the  extremities,  impaired  vision,  loss  of  memory,  and  many  other  symptoms 
of  an  unstrung  nervous  system — a  series  of  grievances  of  the  incurable  nature  of  which 
an  acute  lawyer  takes  care  to  provide  himself  with  ample  testimony,  and  which  will  al- 
ways be  obtained  so  long  as  the  diseases  of  the  vascular  system  and  their  consequences 
monopolize  a  too  prominent  share  of  the  attention  of  our  profession.  I  have  traced  sev- 
eral of  these  persons  in  their  after  career,  the  large  majority  of  whom  entirely  recover. 
I  believe  it  is  to  the  prevalence  of  error  in  the  early  management  of  these  persons,  who 
are  almost  invariably  subjected  to  depletive  treatment,  and  to  the  imperfect  knowledge 
of  nervous  diseases  which  prevails  in  the  profession,  that  large  sums  are  awarded  for  in- 
juries erroneously  supposed  to  be  permanent  and  incurable.  Can  it  be  reasonably  ex- 
pected that  the  truth  will  be  brought  home  to  the  mind  of  a  lawyer  so  long  as  our  own 
opinions  are  yet  uninstructed  upon  it?  Sooner  or  later  their  true  nature  will  become 
established  facts  in  the  minds  of  our  profession,  and  we  shall  no  longer  hear  the  painful 
discrepancies  of  opinion  among  medical  men  that  now  prevail.  The  light  of  improved 
knowledge  will  dissolve  the  daily  mysteries  which  surround  these  cases  in  the  form  of 
supposed  spinal  concussions,  partial  paralysis,  effusions  into  the  theca  vertebralis,  thicken- 
ing of  the  membranes  of  the  brain,  spinal  cord,  and  lesions  of  this  organ  or  that.  These, 
as  Dr.  Sydenham  declares,  are  but  imitations  and  resemblances,  and  not  realities,  and 
that  they  deceive  the  multitude  is  undoubted.  When  real  disease  prevails  there  is  no 
difference  of  opinion  among  medical  men  as  to  its  existence. 

It  is  a  very  interesting  question,  to  investigate  how  far  the  functions  of  the  mind  are 
involved  in  hysteric  disease,  and  how  closely  it  is  connected  with  it,  whether  the  relation 
between  them  is  direct  and  immediate,  or  remote.  In  cases  of  local  pain,  and  also  the 
local  contraction  of  muscles,  arising  either  from  an  excessive  action  of  one  muscle,  or 
from  the  loss  of  harmony  of  action  with  its  antagonist,  as  in  a  permanently  flexed  forearm 
or  finger,  it  seems  difficult  to  identify  the  evil  with  that  part  of  the  brain  which  we  believe 
to  be  the  seat  of  mind.  And  yet  an  inquiry  into  the  past  history  of  such  persons  will 
often  reveal  the  fact  that  they  have  been  at  one  time  or  other  the  subjects  of  general  or 
paroxysmal  hysteria,  or,  in  other  words,  that  they  have  had  hysteric  fits  ;  ancLas  mental 
emotion  is  more  or  less  associated  with  this  form  of  hysteria,  it  would  appear  not  unreason- 
able to  infer  some  remote  relation  between  the  mind  and  this  variety  of  a  disease  appa- 
rently simply  local  in  its  nature.  There  is  something  in  the  mental  development  of  these 
young  persons  very  characteristic.  They  are  quick  and  excitable,  liable  to  sudden  emo- 
tion without  adequate  cause.  In  very  young  persons  the  local  disease  maybe  developed 
before  the  mental  character  is  fully  matured,  but  advancing  years  will  exhibit  its  peculiar 
features. 

It  is  curious  to  observe  the  influence  which  the  nervous  system  exerts  on  the  daily  con- 
dition of  us  all.  When  unstrung  it  preys  upon  ourselves.  It  is  not  in  the  varying  force 
in  our  pulse,  for  that  gauge  is  not  sufficiently  fine  to  detect  the  variations  of  health,  that 
we  can  refer  in  consciousness  of  strength  and  vigor  on  one  day  that  fails  us  on  another. 
It  is  that  our  nervous  system  is  more  or  less  unstrung.  There  is  a  real  illness  and  a  fac- 
titious illness,  and  in  this  we  observe  the  remarkable  influence  of  mind  in  exercising  a 
controlling  power  over  the  body.  People  without  compulsory  occupation,  who  lead  a 
life  of  both  bodily  and  mental  inactivity — people  whose  means  are  sufficiently  ample  to  in- 
dulge in,  and  who  can  purchase  the  luxury  of  illness,  the  daily  visit  of  the  physician,  and, 


400  .    PSYCHOLOGICAL    MEDICINE. 

not  the  least,  the  sympathy  of  friends — these  real  comforts  come  home  to  the  hearts  of 
those  ornamental  members  of  society  who  are  living  examples  of  an  intense  sensibility, 
either  morbid  or  genuine,  who  can  afford  to  be  ill,  and  will  not  make  the  effort  to  be  well. 
They  are,  in  truth,  well  or  ill,  as  you  choose  to  take  it,  and  they  are  only  ill  because  they 
fail  in  mental  effort,  that  mental  resolution  which  is  sufficiently  powerful  to  rouse  the 
dormant  energies  of  the  body  and  throw  off  the  sensations  of  lassitude,  of  unreal  fatigue 
and  weariness  of  body  and  mind.  A  poor  man  cannot  afford  this  indulgence,  and  so  he 
throws  the  sensations  aside  by  mental  resolution. 

There  is  a  real  fatigue  and  a  nervous  or  unreal  fatigue.  A  lady  will  tell  you  she  was 
so  tired  that  she  could  not  walk  another  step.  She  thinks  so,  and  without  an  adequate 
motive  she  cannot  make  the  required  effort.  Give  her  the  motive,  such  as  the  sudden  ill- 
ness of  a  relative  or  friend  at  a  distance,  and  she  will  extend  her  walk  to  miles  without 
effort  or  subsequent  fatigue.  How  is  this  ?  It  is  that  by  a  great  motive  acting  through 
her  mind  she  has  called  upon  those  dormant  powers  of  her  system  which  are  possessed  by 
all  of  us  to  be  employed  on  critical  occasions.  Rarely,  if  ever,  is  the  body  subject  to  a 
degree  of  fatigue  so  great  that  an  adequate  motive  will  not  obtain  renewed  exertion. 
When  a  lady  tells  you  she  can  only  venture  on  a  walk  of  half  a  mile,  you  will  understand 
that  this  effort  is  determined,  by  the  ordinary,  not  the  extraordinary  motive.  It  is  your 
duty  as  her  medical  attendant  to  place  before  her  such  inducements  to  a  greater  effort  as 
shall  call  on  the  exercise  of  her  dormant  power,  the  reserve  fund  of  physical  strength, 
and  she  will  walk  four  times  the  distance  without  fatigue.  A  poor  man  runs  a  race 
against  time,  and  reaching  the  goal  he  drops  from  fatigue.  Offer  him  at  the  moment 
_^ioo  if  he  will  run  one  hundred  yards  farther.  He  will  accept  the  offer,  run  the  re- 
quired distance,  and  then  drop.  This  is  resolution  acting  on  his  muscular  powers 
through  his  nervous  system,  screwed  up  by  an  extraordinary  effort. 

And  this  law  of  Natm-e  is  applicable  to  us  all  in  our  daily  intercourse  with  the  world. 
A  man  resolves  to  accomplish  a  certain  amount  of  work  on  a  given  day,  and  he  com- 
pletes the  task  he  has  assigned  himself  by  virtue  of  his  resolution.  Such  resolution  is 
eminently  protective  against  fatigue. 

A  question  arises  to  one's  mind — Is  hysteria  what  is  termed  a  specific  disease,  or  is  it 
the  invariable  result  of  a  condition  of  health  into  which  all  persons  pass  in  reduced  states 
of  bodily  vigor,  but  only  modified  in  degree  ?  I  presume  it  is  associated  with  a  peculiar 
organism  common  to  man,  but  not  involving  all,  as  some  persons  amenable  to  the  influence 
of  mesmerism  pass  readily  into  profound  sleep,  while  others  are  entirely  unaffected  by  it. 
It  notoriously  is  far  more  common  in  women  than  in  men,  and  in  young  persons  from 
the  age  of  17  to  30,  in  the  unmarried  than  in  the  married.  We  do  not  associate  hysteric 
affections  with  persons  of  either  sex  who  are  characterized  by  vigor  of  mind,  of  strong 
will,  of  strength  and  firmness  of  character.  Such  persons  may  be  reduced  by  protracted 
illness  to  a  condition  of  weakness  both  bodily  and  mental,  but  they  do  not  in  their  re- 
duced strength,  so  far  as  I  know,  exhibit  any  of  the  peculiar  features  of  hysteric  affections. 
There  is  a  remarkable  form  of  hysteria  which  affords  evidence  on  this  subject.  It  is 
notorious  that  the  sight  of  a  person  under  an  hysteric  attack  has  a  tendency  to  involve 
other  hysteric  persons  around  her.  It  has  happened  to  me  several  times  in  my  hospital 
career  to  witness  the  contagious,  or  rather  the  imitative,  form  of  active  or  paroxysmal 
hysteria  on  a  large  scale.  On  one  of  these  occasions,  in  a  ward  of  twelve  females,  no 
less  than  nine  young  women  were  affected  at  the  same  time.  Several  were  so  violent  as 
to  call  for  the  assistance  of  sisters,  nurses  and  other  servants  of  the  establishment  to  re- 
strain them ;  and  inasmuch  as  a  person  under  the  influence  of  hysteria  brings  into  action 
all  the  latent  strength  of  her  muscular  frame,  which  is  greatly  in  excess  of  her  apparent 
strength,  the  services  of  these  attendants  were  scarcely  sufficient  for  the  purpose — several 


HYSTERIA.  401 

requiring  three  or  four  strong  men  to  prevent  injury  to  their  persons.  The  attack  com- 
mences in  the  person  of  one  girl,  who  may  have  been  the  subject  of  some  trivial  operation, 
or  been  brought  under  the  immediate  influence  of  the  disease  by  mental  emotion.  No 
sooner  is  the  condition  of  this  patient  observed  by  her  fellow-patients  than  her  influence 
is  felt  throughout  the  ward,  and  the  second  subject  may  become  involved,  occupying  a 
bed  at  the  remote  end  of  the  room,  and  thus  it  passes  irregularly  from  bed  to  bed,  each 
patient  appearing  to  take  the  disease  in  the  order  of  their  constitutional  liability.  In  the 
course  of  an  hour,  more  or  less,  it  subsides,  and  tranquillity  is  restored,  but  the  evil  only 
slumbers,  and  on  the  following  day  the  same  scene  may  recur — less  violent,  pehaps,  but 
acted  by  the  same  persons  as  at  first.  Some  of  these  patients,  who  were  not  affected  to 
violence,  were  affected  to  tears  and  wept  in  silence,  while  some  few  were  not  implicated 
at  all,  nor  did  they  show  any  tendency  to  sympathize  with  the  disease.  These  curious 
attacks,  though  they  appear  to  the  subjects  of  them 'irresistible,  are  yet  but  the  result  of 
what  has  been  termed  a  surrender,  and  might  be  prevented  by  an  adequate  motive.  The 
mode  adopted  to  arrest  this  curious  malady  consists  in  bringing  these  persons  under  the 
influence  of  some  powerful  mental  emotion,  and  in  making  some  strong  and  sudden  im- 
pression on  the  mind,  through  the  medium  of,  probably,  the  most  potent  of  all  impres- 
sions, fear.  They  are  not  lost  to  consciousness,  and  for  the  moment,  except  in  the  in- 
tensity of  their  paroxysm,  they  will  listen  to  the  voice  of  authority.  Sympathy  and  kind- 
ness, or  tenderness  of  voice  and  manner,  are  worse  than  useless.  They  rather  aggra- 
vate than  mitigate  the  evil.  Ridicule,  to  a  woman  of  sensitive  mind,  is  a  powerful 
weapon,  and  will  achieve  something,  but  there  is  no  emotion  equal  to  fear,  and  a  threat 
of  personal  chastisement  will  not  necessarily  be  required  to  be  carried  into  execution. 
On  two  of  the  occasions  I  have  referred  to,  a  few  quarts  of  cold  water  suddenly  thrown 
on  the  person  of  a  chief  delinquent  instantly  brought  the  ward  to  a  state  of  reason  and 
tranquility.  The  disease  succumbed  to  the  indignity  of  the  treatment.  There  can  be  no 
doubt,  then,  that  a  malady  spreading  by  sympathy  and  cured  by  fear,  has  its  origin  in  the 
mind.  I  think  you  will  find,  on  close  inquiry,  that  nearly  all  cases  of  paryoxysmal  hys- 
teria originate  in  some  form  of  mental  excitement,  and  that  of  a  depressing  character,  such 
as  sorrow  or  disappointment.  It  is  not  the  result  of  mere  emotion.  Joy,  gladness  of 
heart,  or  a  sense  of  pleasure  rarely  produces  it;  yet  it  is  difficult  to  explain  either  its  im- 
mediate or  proximate  origin  in  attacks  occurring  during  sleep.  Sometimes  these  patients 
suddenly  awake  from  sleep  with  severe  palpitations  of  the  heart  leading  on  to  a  direct 
attack.  What  can  be  their  immediate  cause  ?  There  is  no  disease  of  the  agents  of  circu- 
lation, or  any  suspected  variation  in  the  quanity  of  blood  thrown  upon  the  heart  by  which 
to  explain  it.  Whence,  then,  the  eccentric  action  of  this  organ  ?  Possibly  some  mental 
emotion  in  the  form  of  a  forgotten  dream  or  some  other  occult  mental  operation  which 
escapes  cognizance,  such  as  occurs  in  cases  of  somnambulism. 

In  these  current  remarks  on  general  hysteria  we  must  not  lose  sight  of  the  subject 
taken  in  a  surgical  point  of  view.  I  have  stated,  both  in  this  and  in  the  last  lecture, 
that,  under  the  condition  of  impaired  health,  the  nerves  of  a  part  of  the  body  may  be- 
come the  subject  of  a  deranged  action  by  which,  as  Dr.  Sydenham  has  declared,  and  we 
in  our  generation  almost  daily  observe,  so  many  symptoms  of  actual  disease  of  that  part 
may  appear  as  to  give  the  exact  appearance  or  verisimilitude  of  local  organic  change  of 
structure,  when  such  disease  is  entirely  absent.  There  may  be  nothing  apparent  on  a 
first  inquiry  to  associate  the  case  with  hysteria,  whether  local  or  general.  It  is  not  ne- 
cessarily nor  commonly  preceded  by  hysteric  paroxysms.  There  may  be  no  appearance 
of  illness,  no  heat  or  undue  excitement  of  the  system,  nothing,  in  fact,  to  connect  it  with 
hysteric  disease ;  yet,  it  is  nothing  but  local  nervous  exacerbation,  and,  from  the  want  of 
a  better  name,  we  call  it  hysteria.     You  must  not  confound  it  with  simple  neuralgia, 

26 


402  PSYCHOLOGICAL   MEDICINE. 

and,  with  still  less  reason,  with  epilepsy.  It  is  not,  however,  always  easy  to  draw  a  dis- 
tinct line  between  neuralgia  and  hysteria,  for  both  may  have  a  constitutional  origin,  and 
be  amenable  nearly  to  the  same  treatment.  In  neuralgia,  however,  we  have  a  more  gen- 
erally local  and  more  persistent  affection  of  the  nerve.  The  disease  appears  to  be  limited 
to  the  nerve  itself,  the  course  of  which  may  be  traced  by  the  pain,  which  is  often  exces- 
sive ;  whereas,  in  those  cases  of  hysteria  marked  by  local  pain,  the  pain  is  general,  in- 
volving the  structures  around  in  common  with  real  disease  of  the  part  affected.  In  neu- 
ralgia the  disease  is  placed  on  a  recognized  nerve,  and  a  person  is  said  to  have  neuralgia 
of  a  given  nerve,  such  as  the  frontal,  mental,  or  digital.  In  hysteria  any  locality  may  be 
affected  without  reference  to  the  distribution  of  nerves  ;  while  epilepsy  is  characterized 
by  well-marked  symptoms  clearly  of  a  cerebral  origin.  If  you  amputate  a  limb  for  hys- 
teric pain,  you  throw  the  disease  back  on  its  nervous  centre,  and  you  kill  your  patient. 
In  the  early  part  of  my  hospital  career,  I  have  seen  this  fact  more  than  once  exemplified. 
In  such  cases  operative  surgerj'  is  entirely  out  of  place. 

Now,  before  I  proceed  to  illustrate  these  statements  by  reference  to  cases,  of  which  T 
have  an  ample  supply,  I  wish  to  make  a  few  remarks  on  the  relation  between  local  hys- 
teria and  the  nervous  centres — viz.,  the  brain  and  spinal  cord.  Any  facts  that  tend  to 
throw  even  a  gleam  of  light  on  the  connection  between  them  must  be  interesting.  I  re- 
fer to  the  influence  of  anaesthetic  agents,  especially  of  opium  and  chloroform.  In  cases 
of  hysteria  marked  by  local  pain,  relief  is  given  by  the  application  of  opium  to  the  affected 
part — a  fact  which  does  not  confirm  the  generally-entertained  opinion  that  the  local  af- 
fection is  dependent  on  irritation  of  the  nervous  centre.  Select  a  case  of  hysteric  con- 
traction of  the  muscles  of  a  joint — the  elbow  or  fingers.  If  you  administer  chloroform, 
the  contraction  of  the  muscles,  which  may  have  existed  for  months,  and  which  has  re- 
sisted repeated  attempts  to  extend  them,  will  now  yield  to  a  gentle  effort  of  extension, 
and  the  limb  is  immediately  restored  to  apparent  repose.  Supposing  this  morbid  con- 
traction of  one  or  more  muscles  to  be  caused,  as  we  believe,  by  irritation  of  the  nervous 
centre,  how  does  opium  or  chloroform  affect  it  ?  The  effects  of  chloroform  on  the  circu- 
lation are  assuredly  not  in  the  direction  of  health,  for  it  converts  arterial  into  venous 
blood,  or,  at  least,  it  gives  to  arterial  blood  the  dark  color  of  venous,  and  we  can  hardly 
believe  impaired  circulation  of  a  part  of  the  body  compatible  with  its  improved  function, 
and  yet  the  disease  subsides.  This  "  irritation  of  the  nervous  centre,"  as  I  told  you,  does 
not  convey  a  very  clear  idea  of  the  nature  of  the  relation  between  the  respective  parts — viz., 
the  seat  of  the  disease,  and  its  source  or  centre.  Perhaps,  the  nearest  approach  we  can 
make  to  a  solution  of  the  difficulty  is  by  saying  that  these  two  agents — opium  and  chlo- 
roform— suspend  for  the  time  the  influence  of  both  sensory  and  motor  nerves,  under 
which  suspension  the  local  pain  or  the  erring  muscle  partakes  of  the  general  influence  of 
the  ansesthetic.  To  bring  this  morbid  state  of  the  muscle  within  the  influence  of  the 
mind  as  its  cause  is  almost  of  necessity  to  infer  the  local  evil  to  be  wilful ;  but  if  it  were 
so,  the  state  of  unconsciousness  during  sleep  would  remove  it,  which  it  does  not,  for  the 
contraction  is  constant  by  night  and  day,  while  the  specific  influence  of  the  chloroform 
suspends  the  disease,  if  it  does  not  cure  it,  and  the  renewed,  though  partial,  contraction 
of  the  muscle  is  now  prevented  by  mechanical  agency.  The  remarkable  circumstance 
consists  in  this,  that  a  disease  of  long  standing,  which  incapacitates  for  exercise  and  oc- 
cupation, is  removed  in  a  few  minutes  by  the  agency  of  chloroform,  and  the  patient 
placed  at  once  on  the  high  road  to  recovery.  Is  this  curious  fact  confirmatory  or  other- 
wise of  the  origin  of  the  disease  in  the  nervous  centre  ? 

Unfortunately,  hysteric  persons  have  no  exemption  from  real  disease,  and  when  the 
two  are  found  in  combination,  a  difficulty  in  diagnosis  will  frequently  occur  to  test  the 
pathological  knowledge  of  the  surgeon.     The  local  disease  is  accompanied  by  symptoms 


HYSTERIA.  403 

of  an  eccentric  character  that  do  not  legitimately  belong  to  it.  Local  pains  are  aggravated 
in  the  active  stages,  and  do  not  subside  in  a  degree  proportionate  to  the  local  improve- 
ment. A  small  malady,  such  as  a  sprained  wrist  or  ankle,  is  magnified  into  a  large  one. 
The  constitutional  symptoms  take  the  direction  of  hysteria  instead  of  fever.  The  vascu- 
lar system  indicuted  by  the  state  of  the  pulse,  the  skin,  etc.,  is  less  involved  than  the 
nervous,  and  months  will  often  expire  before  recovery  is  complete.  To  a  surgeon,  not 
familiar  with  hysteric  disease,  who  practices  his  profession  with  reference  to  one  only  of 
the  two  systems  of  which  the  body  is  composed,  these  cases  will  always  be  obscure  and 
difficult  of  management.  When  an  injury  occurs  to  the  person  of  a  young  female,  and 
to  many  others  neither  young  nor  female,  hysteric  symptoms  are  almost  certain  to  de- 
velop themselves  in  some  form  or  degree  before  recovery  is  complete. 

[It  is  an  indisputable  fact  that  any  part  of  the  body  can  be  the  seat  of  such  local  de- 
rangement, either  of  the  nerves  of  sensation  or  motion,  as  shall  actually  represent  disease 
in  that  part,  when  no  disease,  properly  so  called,  exists.] 

Cases  of  real  hysteria  maybe  reckoned  by  hundreds  in  the  practice  of  any  one  surgeon. 
The  more  common  seats  are  the  female  breast,  the  side  of  the  trunk,  under  the  ribs,  the 
whole  spinal  region  from  the  atlas  to  the  sacrum ;  any  joint,  but  especially  the  knee ;  the 
stomach,  the  bladder,  and  the  ovaries;  the  muscular  system  of  the  extremities,  indicated 
by  spasm  or  permanent  contraction,  and  the  muscles  of  the  larynx.  But  no  part  of  the 
frame  has  exemption  from  liability,  so  far  as  I  am  aware. 

I  will  first  quote  a  very  simple  case  of  hysteria,  the  evidence  of  which  is  immediate 
and  the  attack  transient.  In  some  slight  forms,  the  patient  loses  all  command  over  the 
voice,  which  suddenly  sinks  to  an  almost  inaudible  whisper,  without  any  other  accompa- 
nying symptom.  I  have  seen  many  examples,  but  that  I  give  occurred  under  my  own 
observation,  as  it  has  probably  in  some  form  occurred  under  that  of  others,  for  it  is  as  old 
as  history.  The  subject  was  a  young  lady,  of  about  20,  as  Sir  B.  Brodie  observes,  of  pale 
complexion,  and  having  cold  hands  and  feet.  While  I  was  engaged  in  conversation  rel- 
ative to  her  health,  I  somewhat  imprudently  remarked  that  a  mouse  was  running  about 
under  the  table  at  the  end  of  the  room.  She  uttered  an  exclamation  of  alarm,  and  in 
an  instant  so  entirely  lost  the  power  of  audible  speech,  that  I  was  obliged  to  approach 
her,  and  to  put  my  ear  close  to  hear  her.  The  ferocious  cause  of  the  mischief  having 
paid  the  penalty  of  its  intrusion  by  the  loss  <of  all  it  possessed  on  earth,  the  lady,  in  the 
course  of  an  hour,  recovered  her  voice.  Had  this  person  been  in  sound  and  vigorous 
health,  she  would  probably  have  sustained  the  shock  to  her  nervous  system  with  less  de- 
rangement of  it.  The  case  is  interesting  as  showing  the  sudden  influence  of  the  mind 
on  a  particular  nerve  in  the  general  system.  Ammonia,  chloric  ether,  henbane,  etc., 
quickly  administered,  would  probably  shorten  the  attack,  and  for  which  agents  brandy 
is  a  good  substitute. 

Cases  of  hysteric  affections  of  the  breast  occur  in  young  persons  from  16  to  20.  They 
are  associated  with  a  disturbed  condition  of  the  genital  system,  but  not  especially  with 
the  functions  of  the  uterus  itself.  Although  the  catamenia  is  often  deranged  and  defect- 
ive, it  is  not  necessarily  so.  The  general  system  is  at  fault,  indicated  by  a  low  circulation — 
frequently  a  chlorotic  aspect,  failing  appetite,  languor,  and  indisposition  to  any  form  of 
active  bodily  or  mental  effort.  In  the  cases  I  have  seen,  the  breast  has  been  small  and 
soft.  The  disease  consists  of  simple  pain  in  the  organ,  one  or  both,  but  more  severe  ia 
one  than  the  other.  It  is  most  active  at  the  catamenial  periods.  The  breast  is  unaltered 
in  form  and  substance.  The  evidence  of  local  inflammation  is  entirely  absent.  Leeches, 
or  other  forms  of  local  depletion,  give  no  relief.  Blisters  and  irritating  plasters  and  oint- 
ments answer  no  useful  purpose.  The  degree  of  pain  varies  with  the  co-ndition  of  the 
health.     For  a  period  it  may  almost  cease — a  period,  coexistent  with  a  change  of  air  and 


404  PSYCHOLOGICAL   MEDICINE. 

occupation,  or  a  residence  of  a  month  or  two  at  the  seaside,  but  the  pain  relapses  on  the 
return  of  the  subject  to  the  ordinary  habits  of  Hfe.  The  pain  is  dull  and  aching,  and 
very  unlike  the  smarting  and  shooting  pain  which  accompanies  abscess,  or  the  more 
formidable  diseases. 

With  this  history  who  will  doubt  the  constitutional  nature  of  the  malady  or  the  efficacy 
of  such  remedies  as  tend  to  change  weakness  for  strength,  to  promote  appetite,  to  keep 
the  circulation  in  action  by  frequent  exercise,  taken  at  least  twice  daily  ? 

Of  examples  of  hysteric  pain  situated  under  the  ribs,  more  commonly  on  the  left  side, 
it  is  needless  to  quote  individual  cases — they  are  so  common.  From  some  cause  not 
very  apparent,  they  are,  however,  seen  less  frequently  than  formerly.  I  attended,  some 
years  ago,  a  young  married  lady,  the  mother  of  three  or  four  children,  the  daughter  of  a 
medical  man  of  large  experience,  by  whose  direction  she  had  been  cupped  about  fifteen 
times  over  the  seat  of  pain.  The  malady  prevailed  in  her  system  in  its  active  form  during 
many  years,  and  she  was  not  free  from  it  when  I  saw  her  at  the  age  of  30.  This  treat- 
ment, which  included  the  local  application  of  leeches  by  the  hundred,  and  blisters  the 
sum  of  which  might  be  calculated  by  the  square  yard,  while  it  gave  no  permanent  relief, 
has  left  its  mark  in  more  senses  than  one  on  person  and  constitution  of  this  lady  for  life. 
At  all  events,  her  excellent  parent  has  the  merit  of  perseverance,  if  not  of  discrimination. 

Among  the  cases  of  sympathetic  or  imitative  forms  of  hysteria  which  I  have  already 
quoted,  two  of  these  females  exhibited  the  scars  of  similar  local  treatment  for  supposed 
organic  disease  under  the  ribs,  and  I  have  seen  many  others.  I  need  hardly  tell  you 
that  this  is  a  constitutional  and  not  a  local  infirmity,  and  must  be  treated  accordingly,  or 
not  treated  at  all.  What  structure  or  organ  occupying  this  region  on  the  left  side,  under 
the  lower  ribs,  can  be  supposed  the  seat  of  this  pain?  It  is  deep-seated,  and  therefore 
the  abdominal  muscles  are  beyond  suspicion.  Is  it  the  colon,  or  the  spleen,  or  the  base 
of  the  left  lung,  or  the  diaphragm  ?  Whichever  structure  is  involved,  if  any,  rely  upon 
it  the  essence  of  the  malady  is  seated  in  the  nerves,  and  the  nerves  only.  If  it  were 
organic  disease,  its  nature  would  become  in  time  palpable.  There  is  this  important 
distinction  between  the  two  affections — that  organic  disease  has  a  crisis,  and  nervous 
affections  for  the  most  part  have  none. 

Spinal  hysteric  affections  are,  perhaps,  of  all  hysteric  maladies  of  thfe  most  common 
occurrence — happily  they  are  becoming  somewhat  notorious.  It  is  in  the  records  of 
pathology,  no  doubt,  that  a  young  female  may  become  the  subject  of  real  spinal  disease; 
but  where  are  the  cases  to  be  found  ?  You  may  pass  through  life  and  not  see  two.  And 
while  I  state  this  opinion  your  minds  may  possibly  revert  to  some  case  you  have  already 
attended  which  you  think  exceptional.  Look  more  closely  into  it,  and  you  will  detect 
your  error.  In  forming  an  opinion  on  any  given  case  on  which  you  may  be  consulted 
hereafter,  you  had  better  make  a  starting-point  from  the  knowledge  of  this  fact,  that 
nothing  in  pathology  is  more  improbable  than  that  a  young  lady  should  be  the  subject  of 
organic  disease  of  the  spinal  column.  Well,  a  case  presents  itself  for  your  opinion.  A 
young  female,  in  any  class  of  life,  in  apparent  health,  pale  or  florid  in  complexion,  bearing 
in  her  appearance  no  indication  of  disease,  complains  of  pain  in  the  back.  This  pain 
may  be  announced  without  surgical  inquiry,  or  may  be  detected  only  on  examination. 
The  spine  is  exposed  while  the  person  is  placed  in  bed.  Pressure  is  made  by  one  or 
more  fimgers  on  the  spinous  processes  of  the  vertebrae,  beginning  with  the  atlas.  On 
reaching  perhaps  the  last  dorsal  or  first  or  second  lumbar  vertebra,  the  girl  utters  an 
exclamation  of  pain,  and  she  instantly  shrinks  from  the  pressure.  The  examination  is 
renewed  again  and  again  with  the  same  result.  Twenty-three  vertebrae  admit  of  pressure 
through  their  final  processes  without  causing  suffering.     Pressure  on  the  particular  one, 


HYSTERIA.  405 

or  perhaps  two,  causes  instant  and  often  severe  pain.  Who  ever  heard  of  real  disease 
attacking  one  or  even  two  vertebrse  only  ? 

I  have  already  told  you  the  probable  result  of  this  inquiry,  but  you,  I  trust,  will  not  be 
deluded.  Be  assured  to  the  extent  almost  of  certainty  that  there  is  no  organic  disease, 
either  of  bone  or  of  any  other  texture.  I  attended  a  girl  in  St.  Bartholomew's  Hospital 
of  about  20  years  of  age.  She  had  the  appearance  of  a  strong  and  healthy  person,  and 
there  was  nothing  in  her  aspect  to  indicate  that  she  was  the  subject  of  disease.  Before  I, 
reached  her  bedside,  the  house-surgeon  informed  me  she  was  the  subject  of  "  spinal 
disease,"  and  I  smiled  at  his  credulity.  To  the  students  around  I  said :  "  If  on  exam- 
ining this  girl  she  makes  an  exclamation  of  pain  and  shrinks  from  the  pressure  of  my 
hand,  rely  on  it  she  has  no  disease  whatever,  and  that  her  case  is  one  of  simple  hysteria." 
On  reaching  the  first  and  second  lumbar  vertebrae  she  uttered  an  expression  of  severe 
pain,  and  nearly  threw  herself  out  of  bed.  The  diagnosis  was  confirmed,  and  she  was 
treated  for  a  nervous  and  not  a  real  disease.  Extract  of  opium  dissolved  in  soap  liniment 
was  rubbed  on  the  spine  for  a  few  days,  and  then  the  opiuin  w^as  omitted,  and  the  back 
generally  rubbed  by  the  hand  twice  daily  with  some  force  of  pressure.  She  was  ordered 
valerian,  bark,  iron,  and  a  full  diet,  with  wine.     Her  recovery  occupied  one  month. 

I  was  consulted  in  the  year  1862  on  the  case  of  a  young  lady  of  about  24  years  of  age. 
She  had  had  "spinal  disease"  for  several  years,  and  many  surgeons  of  more  or  less 
eminence  had  been  consulted  on  her  "very  remarkable  case."  Her  aspect  was  that  of 
a  healthy  person.  She  was  inclined  to  be  stout,  and  exhibited  no  indication  of  serious 
disease,  or  indeed  of  disease  of  any  kind.  During  five  years  her  back  had  been  most 
liberally  cupped,  leeched,  blistered,  and  embrocated  without  benefit.  I  was  informed 
that  the  pain  had  occasionally  intermitted,  that  her  condition  had  improved  for  a  time 
and  then  relapsed,  and  that,  although  nearly  the  entire  five  years  had  been  passed  in  her 
chamber,  and  in  the  horizontal  posture,  yet  that  occasionally  she  would  join  her  family 
and  seek  relief  from  the  monotony  of  her  life  in  the  gaiety  of  the  ball-room,  where  she 
forgot  her  diseased  spine  and  all  its  attendant  miseries,  and  danced  for  hours  with  life 
and  animation.  I  examined  her  back  with  more  than  usual  care.  The  pain,  always  true 
to  its  own  locality,  occupied  the  second  lumbar  vertebra,  and  always  returned  on  the 
pressure  of  my  finger  on  that  particular  spot.  Occupying  her  attention  by  conversation, 
I  gradually  subjected  the  whole  back  first  to  gentle,  and  then  to  severe,  pressure.  "With 
both  hands  I  grasped  the  trunk,  and  moved  it  forcibly  in  all  directions  without  creating 
any  sensation  of  pain.  I  then  passed  the  flat  of  my  hand  rapidly  down  the  spine,  em- 
ploying not  pointed,  but  obtuse  pressure  over  the  whole  surface,  and  thus  satisfied  myself 
that  there  was  no  disease.  After  the  interval  of  a  few  minutes,  pointed  pressure  on  the 
second  lumbar  vertebra  produced  the  same  symptoms  as  at  first.  On  examining  the 
surface,  I  observed  the  mark  of  a  cicatrix  of  about  three  inches  in  length  running  along 
the  side  of  the  affected  vertebra,  and  on  inquiry  I  learnt  that  one  surgeon,  whom  the 
family  had  consulted,  had  deemed  it  necessary  to  look  within  and  below  the  surface, 
under  the  supposition  that  there  might  possibly  be  a  tumor  or  some  morbid  growth,  the 
removal  of  which  would  be  conducive  to  her  recovery  !  Nothing,  however,  was  found, 
and  the  excision  of  a  small  portion,  I  presume  of  the  erector  spinse  muscle,  afforded  no 
permanent  relief — at  least  no  benefit  had  arisen  from  the  operation  at  the  expiration  of 
many  months,  when  I  was  requested  to  see  her.  It  struck  me  that  this  was  carrying  the 
experiment  of  operative  surgery  rather  far,  but  I  did  not  make  any  remark  to  that  effect 
at  the  time.  I  certainly  made  an  inquiry  as  to  the  product  of  the  operation,  and  the 
father  of  the  young  lady  told  me  that  he  was  shown  something,  but  he  was  not  competent 
to  state  exactly  what  it  was.  On  discussing  the  nature  of  the  case  with  the  family  and 
the  attending  surgeon,  I  expressed  my  conviction  of  the  hysteric  nature  of  the  disease. 


406  PSYCHOLOGICAL    MEDICINE. 

and  that  she  was  capable  of  exertion  could  she  be  induced  to  attempt  it.  I  saw  at  once 
that  I  had  failed  to  convey  my  own  convictions  to  the  family,  that  my  opinion  was  not 
satisfactory,  and  that  in  the  judgment  of  the  lady's  father,  a  very  sensible  person,  the 
opinion  of  one  man  could  not  outweigh  that  of  many,  and  that  the  testimony  of  the  many 
was  the  safer  guide.  The  patient  returned  to  her  couch,  on  which  she  may  be  now 
reposing  for  ought  I  know  to  the  contrary,  for  I  saw  her  but  once.  I  had,  however,  the 
satisfaction  to  hear  the  medical  man  say  as  I  left  the  house,  "  I  believe  your  view  of  the 
case  is  the  only  true  one." 

As  treatment  by  means  of  issues  was  formerly  in  great  resort,  and  is  yet  far  from 
being  abandoned  as  a  means  of  checking  the  progress  of  carious  disease  in  the  vertebrse, 
it  is  worth  considering  for  a  moment  the  principle  of  its  action.  To  control  one  dis- 
ease you  make  another,  which  is  supposed  lo  act  as  a  drain  in  carrying  off  the  morbid 
actions  of  the  original  disease  by  derivation,  or  counter-irritation  as  it  is  termed.  An 
issue  is  an  ulcer,  secreting  matter,  and  drawing  more  or  less  on  the  powei^s  of  the  con- 
stitution. An  ulcer  is  a  disease.  All  disease  exercises  a  depressing,  not  an  invigorating, 
influence  on  the  system.  The  sum  total,  then,  is  increase,  not  diminution,  of  the  evil. 
The  morbid  condition  of  true  spinal  affections  is  caries  or  crumbling  of  bone,  not  in- 
flammation. Is  it  probable  that  a  pair  of  secreting  ulcers  can  tend  to  restore  bone  that  is 
lost?  Will  the  capillaries  be  more  likely  to  secrete  material  to  be  converted  into  healthy 
bone  within  the  body  because  you  have  made  an  ulcer  outside  ?  The  actions  going  on 
within  are  those  of  deficiency,  and  not  of  excess.  Here  comes  in  again  the  old  doctrine 
of  inflammation.  The  operation  of  an  issue  is  equivalent  to  that  of  the  lancet,  and  in 
these  days  that  instrument  has  become  obsolete  in  the  hands  of  all  sensible  and  thinking 
men.  I  acknowledge  with  all  regret,  in  looking  back  at  the  early  part  of  my  own  pro- 
fessional career,  to  have  frequently  committed  this  error  in  treatment,  and  I  willingly 
make  retribution  to  another  generation  by  declaring  my  conviction  of  the  entire  futility 
of  an  issue  in  this  description  of  disease  to  answer  any  useful  purpose. 

While  on  a  visit  at  the  house  of  a  friend  in  the  country,  I  was  requested  to  see  one  of 
his  daughters  who  had  been  confined  to  her  room  for  fifteen  months  in  consequence,  as 
I  was  told,  of  diseased  spine.  She  .was  twenty-one  years  of  age.  Her  countenance  was 
pale,  but  not  unhealthy.  She  had  been  condemned  by  a  court  of  surgeons  to  a  long 
confinement  to  the  horizontal  position,  and  she  bore  the  judgment  against  her  with  resig- 
nation and  humility.  From  the  appliances  around  her,  and  the  general  arrangements  of 
the  room,  it  was  obvious  that  the  siege  was  to  be  long  and  vigorously  maintained.  My 
visit  was  not  a  professional  one,  and  I  did  not  propose  to  myself  at  the  time  to  discuss  the 
subject  of  her  disease.  Accident  brought  me  into  contact  with  her  medical  attendant, 
and  in  the  course  of  conversation  with  him  some  features  of  her  case  were  mentioned, 
which  appeared  not  very  consistent  with  real  disease  of  the  vertebrse.  We  examined 
her  carefully,  and  the  consultation  which  ensued  terminated  in  the  proposal  that  his  pa- 
tient should  change  the  horizontal  posture  for  that  of  an  inclined  plane.  In  a  week  she 
sat  upright  in  an  easy  chair,  and  within  a  month  she  joined  the  family  circle,  entered 
into  all  their  pursuits,  and  could  ride  any  reasonable  distance  on  horseback  without 
fatigue. 

I  see  no  advantage  in  multiplying  these  painful  examples  of  hysteric  disease.  They 
have  all  general  characters  in  common,  and  are  amenable  to  the  same  principles  of  treat- 
ment. And  so  with  cases  of  supposed  injury  from  railway  accidents.  Again  and  again 
have  I  heard  medical  men,  physicians,  surgeons,  and  general  practitioners  come  into 
courts  of  law  and  state  their  opinion  that  the  plaintiff  had  sustained  grievous  and  proba- 
bly permanent  bodily  detriment  to  the  spinal  column,  on  the  evidence  of  pain  produced 
by  pressure  of  the  finger  on  one  or  more  of  the  spinous  processes — evidence  far  more 


HYSTERIA,  407 

than  counterbalanced  by  the  fact  that  these  deluded  persons  have  walked  unaided  into 
court,  and  have  stood  or  sat  in  the  witness-box  for  three-quarters  of  an  hour  while  under 
examination. 

No  evidence  of  their  reputed  symptoms  is  obtainable  either  through  the  eye  or  the 
touch  of  the  surgeon.  There  is  nothing  palpable,  nothing  organic.  You  take  the  asser- 
tions of  your  patient  on  trust,  you  identify  yourself  with  his  case ;  you  place  an  object 
before  him,  and  he  declares  he  cannot  see  it ;  you  refer  to  an  occurrence  that  happened 
last  week,  he  declares  that  he  does  not  remember  it.  He  suffers  incessant  pain  in  his 
back  ;  he  staggei'S  in  his  walk,  occasionally  coming  to  a  harmless  fall ;  he  has  convulsive 
twitchings  in  his  leg,  occurring  chiefly  in  bed,  which  he  says  he  cannot  control.  He 
passes  blood  in  his  urine,  which  always  escapes  the  notice  of  others,  for  it  is  invariably 
passed  at  the  water-closet,  and  at  no  other  time;  but  on  inquiry  you  will  find  that  this 
afflicted  person  can  walk  four  or  five  miles  ;  that  as  regards  his  vision  his  iris  acts  well, 
and  the  ophthalmoscope  detects  nothing ;  his  appetite  for  food  is  sufficient  for  perfect 
nutrition.  And  let  me  ask  you  finally  whether  on  these  conditions  it  is  more  than  re- 
motely possible  such  a  person  can  be  the  subject  of  any  serious  organic  disease.  But 
presuming  on  the  possibility  of  such  contradictory  evidence  occurring  in  a  single  and 
exceptional  case  of  real  disease,  will  your  credulity  reach  so  far  as  to  admit  of  their  fre- 
quent occurrence  ?  To  you  such  cases  will  be  presented  singly  and  individually,  but 
they  are  brought  into  courts  of  law  in  multitudes. 

One  of  such  cases  1  will  give  you  as  an  example  :  A  man  without  property  or  profes- 
sion brought  an  action  against  a  railway  company  for  injury  to  his  spine.  This  state- 
ment, on  the  face  of  it,  is  an  absurdity.  How  can  a  man  without  property  bring  an 
action  at  law  ?  Well,  he  applies  to  a  lawyer,  who  undertakes  the  case  on  his  behalf, 
with  a  certain  compact  and  understanding  as  to  the  question  of  future  payment.  Thus 
the  lawyer  becomes  the  plaintiff,  and  the  plaintiff  the  witness  in  his  own  case.  The  man's 
injury  was  made  out  to  the  entire  satisfactton  of  the  jury,  and  very  heavy  damages  were 
awarded  by  them,  coupled  with  severe  comments  on  the  negligence  of  the  railway 
directors. 

It  was  positively  known,  at  the  time,  by  several  persons  engaged  in  the  action,  among 
whom  was  a  detective  officer,  that  within  a  few  days  of  the  trial  the  plaintiff,  or  the  wit- 
ness, whichever  you  please  to  term  him,  had  walked  a  match  against  another  man  ! 
Yet  this  man  was  declared  on  authority  to  have  sustained  a  permanent  injury  of  his  spinal 
column ! 

With  respect  to  hysteric  affections  of  joints,  knee  cases,  etc.,  they  are  in  truth  as  com- 
mon as  Sir  B.  Brodie  has  declared  them  to  be,  and  I  thoroughly  corroborate  all  he  has 
said  on  the  subject  of  this  most  important  and  interesting  disease.  Three-fourths  of  all 
knee  cases  in  the  upper  classes  of  society,  says  this  great  authority,  are  not  cases  of  in- 
flammation, though  they  appear  so.  There  is  no  organic  disease  whatever  in  the  joint. 
They  are  cases  of  local  pain,  originating  in  impaired  health.  They  are  not  amenable 
to  treatment  for  inflammation  and  its  consequences.  Your  liability  to  an  error  in  diag- 
nosis is  just  in  proportion  to  the  supposed  infrequency  of  local  nervous,  as  compared 
with  vascular,  derangement.  The  knee  is  by  far  the  most  frequent  seat  of  these  affec- 
tions, and  the  cases  are  found  among  young  women  not  in  the  lower  classes  of  life — but 
even  this  class  is  not  exempt.  You  will  find,  on  the  occasion  of  your  first  visit,  the 
patient  walking  lame.  This  lameness  has  existed  for  several  days,  probably  weeks,  before 
attention  has  been  attracted  to  it,  and  has  come  on  very  gradually.  The  joint  is  stiff — 
not  that  it  won't  bend,  but  the  movement  is  painful.  There  may  be  some  increased  heat 
in  the  joint,  when  compared  with  that  of  the  opposite  limb,  but  not  much  in  degree. 
The  knee  is  slightly  swollen.     If  you  see  the  case  after  treatment  has  commenced — i.  e.. 


408  PSYCHOLOGICAL    MEDICINE. 

after  the  repeated  application  of  leeches,  blisters,  and  tincture  of  iodine  (the  almost  uni- 
versal agent  in  difiSculty) — the  swelling  will  be  palpable,  and  the  outline  of  the  joint  has 
undergone  a  change.  As  the  case  progresses,  the  lameness  increases,  but  the  aspect  of 
the  joint  remains  as  in  the  first  stage — neither  the  swelling  nor  the  heat  increasing  in  the 
same  proportion.  In  this  condition  the  limb  may  remain  for  months,  or  even  for  years, 
subject  to  the  same  treatment,  without  improvement.  One  feature  in  this  case  ought  to 
have  struck  you  as  worthy  of  notice — viz.,  that  so  many  months  have  passed  without 
organic  change ;  the  joint  is  neither  stiffer,  larger,  nor  hotter  than  it  was  in  the  early 
stage  of  the  treatment.  I  say  it  ought  to  have  struck  you.  Perhaps  it  has  not !  The 
aspect  of  this  lady  is  that  of  unhealthy  She  has  become  pale,  partly  from  depletion, 
partly  from  loss  of  exercise.  Her  pulse  is  weak,  her  appetite  bad,  and  catamenia,  as  a 
rule,  defective.  You  fear  to  give  tonics  and  alcohol,  lest  you  aggravate  the  supposed 
local  inflammation. 

Having  exhausted  the  negatives  in  treatment,  you  now  venture  on  an  onward  step,  and 
you  give  bitter  infusions,  gentian,  cascarilla,  -v^ath  ammonia,  and  ether.  But  you  are 
still  behind  the  necessities  of  the  case  ;  you  have  adopted  from  the  beginning,  a  false 
diagnosis,  and  the  difficulty  is  now  to  get  back  to  the  right  groove.  There  is  only  one 
course :  begin  afresh,  and  treat  your  case  on  a  different  principle  ;  convince  yourself  that 
nerves  may  go  wrong  as  well  as  arteries  and  capillaries,  and  as  you  treat  excessive  action, 
rightly  or  wrongly  in  the  bloodvessels  by  local  depletion,  so  apply  such  remedies  as 
check  excessive  action  of  nerves  in  the  form  of  opium,  belladonna,  chloroform,  etc 
Build  up  the  health  by  increasing  the  force  of  the  circulation.  The  agents  are  a  thor- 
oughly nutritious  diet,  wine  frequently  in  small  quantities,  tincture  of  bark,  iron,  fresh 
sea  air,  change  of  locality  and  associations,  agreeable  mental  occupation.  Assure  your 
patient  she  has  no  real  disease,  but  the  semblance  only.  Leave  the  functions  of  the  ali- 
mentary canal  to  take  care  of  themselves.  The  constipation  incidental  to  a  low  innu- 
tritions diet,  and  an  inactive  life,  will  subside  under  the  influence  of  a  nutritious  one ; 
improved  health  will  restore  its  functions.  There  is  no  real  harm  in  a  day's  constipation ;  it 
is  sometimes  a  good.  At  all  events  leave  the  bowels  alone.  With  regard  to  the  joint,  rub  in 
some  blue  ointment  and  extract  of  opium,  in  the  proportion  of  one-third  of  the  latter,  and 
roll  it  firmly  with  a  flannel  bandage.  Encourage  moderate  daily  exercise  on  a  level  ground, 
on  a  carpet,  or  on  a  lawn.  If  the  case  is  chronic  don't  be  disappointed  if  the  progress  be 
yet  protracted  to  weeks.  The  pain  and  the  stifi"nessmay  subside  very  slowly,  by  virtue  of 
their  long  possession  by  the  joint;  but  you  are  in  the  right  path,  and  rely  upon  it  your 
patient's  recovery  will  justify  the  sound  principle  of  your  treatment. 

In  the  course  of  last  year  I  was  consulted  by  the  family  of  a  young  lady  of  i8  years 
of  age,  living  at  a  distance  from  London,  relative  to  an  affection  of  the  knee  from 
which  she  had  been  suffering  for  a  period  of  ten  months.  The  joint  was  stiff"  and  pain- 
ful ;  she  moved  about  on  crutches  ;  there  was  no  considerable  amount  of  heat;  and  what 
alteration  existed  in  the  form  and  outline  of  the  knee  was  due  to  the  activity  of  the  past 
treatment ;  the  tissues  had  lost  their  natural  softness  and  flexibility  ;  the  joint  had  been 
repeatedly  leeched  and  blistered,  and  subjected  to  the  application  of  liniments  in  variety 
of  color  and  composition ;  an  issue  had  been  made  on  the  inner  side  of  the  patella,  which, 
judging  from  the  cicatrix  it  left  behind,  had  not  been  a  small  one,  and  the  curative  in- 
fluence of  which  had  not  been  discoverable  during  four  months,  at  the  expiration  of 
which  nature  was  allowed  to  heal  it. 

I  considered  this  a  case  of  hysteria,  on  the  following  evidence  :  the  subject  was  a 
young  lady  of  an  hysteric  age.  She  had  sustained  no  sudden  injur}-  to  the  joint,  neither 
blow,  nor  fall,  nor  strain.  The  malady  was  gradual  and  spontaneous.  Had  the  disease 
been  of  the  inflammatory  class,  the  remedies  would  have  probably  long  since   cured 


HYSTERIA.  409 

it.  There  was  no  appearance  of  disorganization  otherwise  than  integumental.  The  pain 
was  generally  aggravated  at  the  catamenial  periods.  Bending  the  joint  afforded  no  evi- 
dence of  disease  within  it,  no  grating  or  roughness  of  the  cartilaginous  surfaces.  The 
pain  varied  greatly  in  intensity  at  different  periods.  This  evidence  was  sufficient,  and, 
to  my  judgment,  conclusive.  I  strapped  up  her  joint  in  an  opium  plaster.  She  took 
bark,  and  iron,  and  wine,  and  in  a  fortnight  began  to  walk  about  without  her  crutches ; 
but  two  months  had  elapsed  before  her  recovery. 

Many  years  ago,  when  I  was  less  familiar  with  hysteric  affections,  I  attended  the  case 
of  a  lady  of  19  in  conjunction  with  Mr.  Stanley.  We  both  deemed  the  disease  to  belong 
to  the  class  of  inflammation,  and  conjointly  adopted  the  usual  remedies  so  indiscriminately 
resorted  to  in  all  painful  affections  of  joints.  Many  weeks  elapsed  without  improvement, 
and  I  remember  that  we  discussed  with  some  anxiety,  the  probable  issue  in  abscess, 
destruction  of  ligaments,  absorption  of  cartilage,  and  ultimate  amputation  of  the  limb. 

One  day  my  patient  informed  me  that  her  sister  was  going  to  be  married,  and  that,  cost 
what  it  might,  she  had  made  up  her  mind  to  attend  the  wedding.  At  this  proposal  I 
shuddered.  Having  expatiated,  to  no  purpose,  on  the  probable  consequences  of  so  rash 
an  act,  with  all  the  force  of  language  I  could  command,  I  determined  to  give  stability  to 
the  joint  for  the  occasion,  and  I  strapped  it  up  firmly  with  adhesive  plaster.  On  the  fol- 
lowing day  I  visited  her.  She  told  me  that  she  had  stood  throughout  the  whole  cere- 
mony, had  joined  the  party  at  the  breakfast,  and  returned  home  without  pain  or  discom- 
fort in  the  joint.     Within  a  week  her  recovery  may  be  said  to  have  been  complete. 

This  case  first  brought  home  to  my  mind  the  nature  and  the  frequency  of  hysteric  disease. 

[Mr.  Skey,  after  some  preliminary  remarks,  proceeds  to  give  a  few  examples  of  the 
less  common  forms  of  hysterical  disease.] 

A  young  woman,  aged  24,  was  admitted  into  one  of  my  wards  at  the  hospital,  who  was 
the  subject  of  difficult  deglutition.  She  was  a  very  respectable  person  in  chai-acter  and 
position,  and  had  been  for  several  years  a  much-esteemed  servant  in  a  good  family,  and 
was  a  young  woman  of  some  education.  For  two  months  previous  to  her  admission  she 
had  complained  of  difficulty  of  swallowing  her  food.  As  the  evil  appeared  to  increase, 
the  family  medical  attendant  was  consulted,  by  whom  she  was  treated  for  a  stricture  of 
the  oesophagus.  One  or  more  consultations  were  held  on  her  case,  and  the  oesophagus 
examined  carefully  by  means  of  probangs  and  bougies.  These  instruments,  how- 
ever, failed  to  pass  a  given  spot  corresponding  with  the  base  of  the  neck,  about 
one-third  from  the  commencement  of  the  tube.  She  had  no  local  pain  whatever. 
As  the  obstruction  increased,  nothing  but  semi-liquid  food  passed  into  her  stomach,  and 
this  was  only  effected  with  a  difficult  and  painful  effort.  She  became  emaciated  by  rea- 
son of  defective  nutrition,  and  at  the  time  of  her  admission  into  the  hospital  was  weak 
and  somewhat  attenuated  in  form.  For  many  weeks  she  had  taken  no  description  of 
solid  food,  and  even  liquids  passed  the  obstruction  with  difficulty.  The  malady  now 
assumed  a  serious  form,  and  with  a  view  to  additional  advice  she  was  sent  to  the  hospital. 
The  case  was  reported  to  me  on  her  arrival  as  that  of  "  stricture  of  the  oesophagus,"  and 
I  will  tell  you  the  preliminary  train  of  thought  that  passed  rapidly  through  my  mind  be- 
fore I  opened  my  lips  to  the  students  on  the  subject.  Real  stricture  of  the  oesophagus  is 
at  all  times  a  rare  disease.  When  present  it  is  almost  invariably  a  cancerous  affection. 
Cancer  is  a  very  rare  disease  at  this  woman's  age.  P'or  so  serious  a  malady  as  cancer 
she  does  not  look  ill  enough  ;  for  though  the  presence  of  cancer  of  the  breast  occurring  at 
a  later  period  of  life  by  twenty  years  may  be  for  a  time  compatible  with  fair  average  health, 
cancer  of  the  oesophagus  stamps  the  constitution  early.  She  is  of  an  hysteric  age,  and 
though  thin,  she  does  not  look  absolutely  ill.  There  is  nothing  of  disease  in  her  aspect, 
nothing  that  may  not  be  referred  simply  to  defective  nutrition.     The  history  of  her  case 


410  PSYCHOLOGICAL    MEDICINE. 

was  given  me  by  her  medical  attendant,  who  was  present  on  the  occasion,  and  I  had  no 
hesitation  in  recording  her  disease  as  "  hysteria."  I  declined  the  use  of  a  probang  or 
bougie  which  lay  on  the  table  before  me,  and  I  simply  said,  "  We  will  endeavor  to  re- 
move the  obstruction  without  the  aid  of  instruments  of  any  kind."  Her  catamenial  dis- 
charge had  been  regular  throughout.  I  ordered  her  bark,  iron,  valerian,  wine,  milk  with 
brandy — each  to  be  given  in  the  largest  quantities  at  the  shortest  intervals  consistetit  with 
reason  attd  moderation  ;  tliree  times  in  twenty-four  hours,  enemata  of  thick  soup  with  an 
ounce  of  brandy.  These  various  agents  were  absorbed  into  her  system  with  the  greatest 
advantage  to  her  health.  Within  a  week  she  could  swallow  finely  minced  animal  food, 
and  in  three  weeks  she  ate  a  portion  of  a  rump  steak  without  difEcultj',  and  was,  in  fact, 
convalescent.  She  was  in  high  spirits  at  her  recovery,  and  the  only  vexation  she  suffered 
arose  from  my  refusal  to  pass  a  probang  down  her  throat  before  she  left  the  hospital. 
This  I  peremptorily  declined  to  do,  assuring  her  that  a  probang  of  rump  steak  was  a  far 
more  efficient  test  of  her  recovery-  than  any  instrument  in  surgeiy  bearing  that  name. 

A  young  lady  of  i8,  and  of  slight  form,  was  brought  to  me  from  the  countiy  withgas- 
trodynia.  For  upwards  of  a  year  she  had  suffered  intolerable  pain  in  the  stomach  on 
taking  food  of  any  description.  She  was  much  emaciated,  and  her  pulse  extremely 
feeble.  Neither  trouble  nor  expense  had  been  spared  in  her  treatment.  Her  family  had 
consulted  medical  men  of  eminence  in  more  than  one  metropolis,  but  the  severity  of  the 
pain  continued  in  spite  of  treatment.  On  entering  the  drawing-room,  I  heard  the  sound 
of  suffering  from  an  adjoining  room,  and  I  was  told  that  my  future  patient  was  paj'ing 
the  penalty  of  a  slight  meal  of  arrowroot,  of  which  she  had  swallowed  a  few  table-spoon- 
fuls only.  Having  intruded  myself  into  the  room  somewhat  unexpectedly  by  its  occu- 
pants, I  saw  this  young  lady  in  a  condition  of  great  suffering,  in  the  upright  position, 
leaning  her  head  upon  her  mother's  shoulder  and  sobbing  painfully.  In  the  course  of 
a  quarter  of  an  hour  I  had  obtained  some  insight  into  her  case,  but  I  could  not  fail  to  ob- 
serve that  the  mother  habitually  interposed  replies  to  questions  addressed  to  the  daughter, 
and  I  explained  to  her  the  necessitj'  of  my  obtaining  the  answers  to  my  inquiries  direct 
from  her  daughter.  At  my  request  she  left  the  room.  Up  to  that  time  I  had  but  an  im- 
perfect knowledge  of  the  case,  but  I  then  led  the  conversation  to  subjects  which  carried 
the  girl  away  from  her  malady  and  all  its  associations.  I  spoke  of  her  home  and  the 
scenery  around  it,  of  which  I  described  the  general  characters,  and  enlarged  on  the 
beauty  of  the  neighborhood,  the  lovely  rides  and  excursions,  etc.,  and  in  all  of  which  I 
was  tolerably  successful,  considering  that  at  that  time  I  had  never  seen  it.  However,  the 
description  was  sufficiently  accurate  for  my  purpose,  for  it  succeeded  in  distracting  the 
young  lady's  attention  from  her  suffering,  and  during  the  few  minutes  which  this  conver- 
sion occupied  she  was,  to  all  appearance,  entirely  free  from  pain.  She  talked  freely  and 
cheerfully,  and  not  the  slightest  reference  by  either  of  us  to  her  former  suffering.  I  then 
changed  the  subject  by  saying,  "  I  think  your  pain  has  flown  away,"  when  she  immedi 
ately  resumed  her  cr}'ing  fit  and  sobbed  as  before.  She  assured  me  she  was  in  great  pain, 
and  the  sensation  had  been  but  suppresssed.  That  this  was  a  case  of  severe  hysteria  was 
highly  probable,  even  had  I  gone  no  further  with  the  evidence,  relative  to  which  the  fol- 
lowing thoughts  occurred  to  my  mind.  What  could  be  the  nature  of  this  pain  if  not 
hysteric?  I  was  told  by  her  family  that  pain  followed  the  act  of  deglutition,  not  re- 
motely or  at  any  interval  of  one  or  more  hours,  but  almost  as  immediately  as  the  food  could 
reach  the  stomach.  This  could  not  be  dyspeptic  or  common  gastrodynia,  which  waits 
on  the  process  of  digestion,  and  rarely  occurs  within  a  period  of  two  hours  of  taking 
food.  There  is  one  disease  only  of  the  stomach  in  which  pain  follows  the  admission  of 
food  into  it,  and  that  occasionally  only — viz.  :  cancer.  Was  it  probable,  or  scarcely  more 
than  possible,  that  this  girl  of  i8  could  have  been  for  so  many  months  the  subject  of  un- 


HYSTERIA.  411 

detected  cancer  of  the  stomach  ?  If  cancer,  could  the  attendant  pain,  so  severe  as  it  ap- 
peared at  the  commencement  of  my  visit,  be  suspended  by  conversation  ?  It  was  neither 
gastrodynia,  the  result  of  indigestion,  nor  cancer;  and  if  not,  what  remains  behind  to 
elucidate  the  case  ?  It  could  be  nothing  but  hysteria,  and  hysteria  alone  could  solve  the 
mystery.  But  she  had  been  treated  for  gastrodynia,  and  treated  for  cancer,  but  she  had  not 
been  under  treatment  for  hysteria,  simply  because  these  varieties  of  local  hysteria  have 
never  yet  fixed  themselves  on  the  attention  of  the  profession.  To  tell  a  practitioner  of 
the  old  school  that  a  young  lady  was  the  subject  of  hysteria  of  the  stomach  would  be  to 
raise  a  smile  at  your  expense. 

It  would  be  an  unprofitable  employment  of  our  time  were  I  to  enlarge  on  the  subject 
of  the  previous  treatment.  The  remedies  included,  in  different  proportions  and  in  vary- 
ing doses,  ammonia  and  other  alkalies,  under  the  mistaken  supposition  of  acid  secre- 
tion ;  opium  in  various  forms,  creosote,  bismuth  in  small  and  large  quantities,  mineral 
acids,  etc.,  etc. 

How  difficult  it  is  to  ascertain  beyond  all  question  the  real  value  of  many  drugs  in  daily 
use  amongst  us.  Although,  in  common  with  others,  I  have  frequently  employed  the 
trisnitrate  of  bismuth,  I  have  to  this  hour  no  conviction  of  its  utility.  This  case  did  not 
terminate  so  satisfactorily  as  I  hoped.  That  it  was  a  case  of  hysteria  admits  of  no  doubt, 
but  I  had  difficulties  to  contend  with  in  the  domestic  management  of  the  young  lady. 
Although  her  symptoms  remitted  greatly  under  the  use  of  remedies,  she  did  not  entirely  re- 
cover in  the  brief  period  of  three  or  four  weeks  during  which  she  was  under  my  care. 
I  gave  her  small  doses  of  ferrocitrate  of  quinine,  two  or  three  times  a  day  a  wine  glass  of 
port  wine  boiled  with  rice,  and  I  ordered  a  plaster  of  the  fluid  extract  of  opium  to  be  ap- 
plied on  the  epigastrium.  If  coupled  with  these  remedies,  I  could  have  separated  the 
girl  from  her  family,  whose  sympathies  with  her  were  far  too  redundant  for  her  benefit, 
I  think  she  might  have  been  cured  in  one  month.  In  a  case  of  this  kind  a  good  domestic 
moral  treatment  is  indispensable  to  success. 

Hysteric  affections  of  the  ovaries  are  extremely  common.  Several  of  such  examples 
1  attended  with  my  late  friend  Dr.  Rigby.  The  cases  I  have  seen  have  occurred  in 
young  females  of  between  20  and  25  years  of  age.  They  are  characterized  by  deep-seated 
aching  pain  in  the  region  of  the  ovary  about  two  inches  above  the  crural  arch.  My  own 
observation  would  lead  me  to  say  that  the  right  organ  is  more  frequently  affected  than 
the  left,  but  this  is  probably  accidental.  Like  other  hysteric  affections,  its  severity  va- 
ries with  the  constitutional  health,  mental  and  bodily.  It  yields  but  slowly  to  remedies, 
and,  though  mitigated,  it  often  returns  at  longer  or  shorter  intervals.  I  have  applied 
opium  locally  with  advantage,  but  an  entire  chaftge  of  air,  scene  and  occupation,  com- 
bined with  tonic  treatment,  are  indispensable  to  recovery. 

Dr.  Samuel  Wilks,  Physician  to,  and  Lecturer  on  the  Practice  of 
Medicine,  at  Guy's  Hospital,  says : 

As  in  hysteria  the  nervous  system  is  deranged,  so  every  part  of  the  body  may  suffer — 
the  function  of  every  organ  may  be  disturbed,  as  well  as  the  nerves  themselves  disordered 
in  all  possible  manners.  Let  us  look  to  some  of  these  irregularities.  First,  the  nervous 
system  proper  may  suffer. 

The  motor  system  may  be  depressed  or  excited ;  thus  paralysis  is  a  very  common 
hysterical  symptom,  affecting  more  especially  the  lower  limbs.  A  leg  cannot  be  moved, 
or  both  legs  are  the  subject  of  paraplegia.  As,  in  such  cases,  the  cause  is  want  of  nervous 
energy,  so  you  will  perceive  the  peculiarity  of  these  cases — that  rousing  of  the  will  is 
often  sufficient  to  put  fresh  vigor  into  the  system  and  cure  the  complaint.     A  sudden 


412  PSYCHOLOGICAL  MEDICINE. 

alarm  has  often  cured  the  patient  who  has  been  considered  as  hopelessly  paralyzed,  and 
this  gives  us  an  insight  into  the  correct  treatment.  I  need  not  dwell  further  on  this 
subject,  as  I  have  already,  on  more  than  one  occasion,  shown  you  the  importance  of  the 
moral  treatment  of  hysteria.  A  young  lady  has  a  complaint  of  an  imaginaiy  kind,  and 
you  visit  her  daily,  and  treat  it  as  if  it  were  a  reality;  the  consequence  is  that  it  is  per- 
petuated, and  you  have  assisted  in  making  it  a  peipetuity.  You  understand  the  real  seat 
of  the  complaint — you  attack  that,  and  cure  your  patient.  When  I  have  had  under  my 
care  here  cases  of  paraplegia  of  years'  duration,  most  assiduously  treated  by  medicine, 
and  at  length  cured  by  moral  means,  I  cannot  speak  too  highly  of  the  method.  These 
cases  are  not  often  difficult  to  diagnose,  since  in  a  real  paraplegia  the  patient  grows  thin, 
bedsores  appear,  paralysis  of  the  bladder  and  rectum  may  be  present,  and  the  patient  feels 
ill,  whilst  in  the  case  of  hysterical  paraplegia  the  patient  remains  plump ;  there  is  no 
trouble  with  the  bladder,  or,  if  any,  it  is  retention  of  urine ;  the  abdomen  is  tympanitic, 
bowels  confined.  The  physiognomy  of  the  patient  and  her  surroundings  sufficiently 
indicate  the  nature  of  the  case.  She  has  taken  to  her  bed  as  if  for  the  remainder  of  her 
days,  and  all  is  arranged  accordingly — the  stitching,  the  embroidery,  the  religious  books 
where  they  can  be  comfortably  reached,  and  she  generally  receives  more  sympathy  from 
the  clergymen  and  the  lady  visitors  than  do  cases  of  real  illness.  The  fact  is  that  there 
are  no  painful  and  loathsome  circumstances  attending  her  case,  and,  from  her  conversation 
and  industry  with  her  hands,  it  is  regarded  as  an  "  interesting  "  one. 

Then,  besides  loss  of  motion,  there  is  perversion  of  motion,  and  we  witness  sometimes, 
as  a  result  of  hysteria,  some  of  the  strangest  movements  which  you  can  conceive.  These 
are  not  of  that  irregular  kind  which  we  witness  in  chorea,  but  are  usually  of  a  rhythmical 
character ;  thus,  instead  of  the  body  or  arms  being  constantly  writhed  about  in  various 
directions,  they  are  more  slowly  or  regularly  bent  in  a  given  manner.  Thus  a  girl  was 
in  the  clinical  ward  two  years  ago,  who  sat  in  a  chair,  and  was  constantly  bending  or 
bowing  forward,  as  if  saluting  all  those  present.  This  continued  for  several  months 
before  she  got  better.  In  this  case,  as  in  all  others,  the  greatest  discomfort  was  produced 
by  the  use  of  any  forcible  means  to  restrain  the  movements ;  the  cause  lies  in  the  centres 
within,  and  no  approach  to  a  cure  is  produced  by  attacking  the  effect.  In  several  other 
cases  the  arm  is  in  constant  and  regular  motion,  as  if  acted  on  by  clockwork.  This  form 
has  received  the  name  of  malleation.  I  remember  a  case  of  Dr.  Barlow's,  where  the 
woman  had  constant  quick  breathing,  and,  what  is  remarkable,  every  inspiration  occurred 
with  a  beat  of  the  heart.  This  continued  for  weeks.  I  have  quite  lately  been  visiting 
a  child  who  has  died  with  this  form  of  hysteria.  After  having  various  strange  symptoms 
for  some  months,  she  took  to  sitting  at  the  side  of  the  bed,  and  having  some  person  or 
object  before  her  which  she  could  continually  keep  thumping  with  her  fists  or  head  all 
day  long.  Any  restraint  only  added  to  the  irritation.  Chloroform,  opium,  conium,  and 
other  remedies,  in  large  doses,  produced  only  a  temporary  effect,  and  she  at  last  died 
utterly  exhausted,  and  wasted  almost  to  a  skeleton.  There  was  no  disease  found  in  the 
brain. 

Then,  again,  we  meet  with  permanent  spasm  as  an  hysteric  symptom,  seen  more 
especially  in  the  hand,  which  is  firmly  clenched,  the  tendons  becoming  rigid  and  the 
muscles  contracted  when  the  hand  is  forcibly  opened.  Then,  again,  the  whole  body 
may  be  affected  after  the  manner  of  tetanus.  This  is  more  often  seen  in  an  acute  attack 
of  hysteria,  but  the  lockjaw  may  remain  as  a  very  troublesome  and  constant  symptom. 
I  draw  your  attention  to  the  fact,  for  it  requires  often  all  our  acumen  in  order  to  distin- 
guish a  real  disease  from  an  hysteric  one.  Then,  also,  you  may  have  that  remarkable 
condition  known  as  catalepsy.  This  in  its  purity  is  not  very  common,  although  I  have 
seen  two  cases  of  it  in  the  hospital.     One  of  my  patients  would  sink  into  a  kind  of  swoon 


HYSTERIA.  413 

or  deep  sleep,  during  which  condition  she  would  stand  perfectly  still  in  the  middle  of 
the  ward,  or,  if  in  bed,  would  remain  in  any  position  in  which  you  chose  to  place  the 
body.  Minor  degrees  of  the  cataleptic  state  are  frequently  met  with,  and  not  uncom. 
monly  in  the  epileptic  of  both  sexes,  especially  after  the  occurrence  of  a  fit.  During  the 
drowsy  stage  which  follows,  you  will  frequently  find  that  the  patient's  limbs  will  remain 
in  any  posture  in  which  you  place  them.  You  will  observe,  in  fact,  that  the  whole 
nervous  system  is  deranged  in  hysteria.  You  will  have  evidence  of  irritation  of  the 
cerebrospinal  system  in  the  movements  I  have  mentioned,  and  in  the  strange  mental 
vagaries ;  then  also  of  the  deadening  of  the  centres,  as  seen  in  the  paraplegia  and  in  this 
disposition  to  lethargy.  We  are  sometimes  called  in  to  a  person  lying  perfectly  insen- 
sible, and  apparently  as  if  near  her  end,  but  it  is  a  mere  phase  of  hysteria.  An  extreme 
form  of  this  condition,  when  continued,  is  usually  styled  trance.  The  whole  nervous 
system  may  be  so  lowered  in  tone  that  the  person  lies  helpless  and  insensible,  but  the 
functions  of  life  slowly  go  on.     This  state  may  last  for  a  great  length  of  time. 

Then  as  regards  the  nerves  of  sensation,  it  may  be  said  that  invariably  these  are  in 
some  way  altered  in  hysteria.  More  commonly  there  is  hyperesthesia  of  some  of  the 
senses.  The  patient  cannot  bear  the  light,  or  the  least  sound  troubles  her,  but  more 
usually  it  is  the  common  sensation  which  is  affected.  Thus,  sometimes  no  part  of  the 
body  can  be  touched  without  the  patient  shrinking — I  mean  the  body  proper,  as  the  chest 
and  abdomen.  Often  it  is  some  particular  part,  the  more  usual  spots  being  those  which 
are  tender  in  many  persons  when  their  "  nerves  are  low,"  as  the  middle  dorsal  vertebrae, 
the  vertex,  and  the  left  side.  You  will  find  many  nervous  persons  flinch  when  you  touch 
them  in  these  places.  Then  there  may  be  some  particular  spot  to  which  the  whole 
attention  of  the  patient  is  directed  until  that  place  is  believed  by  her  to  be  the  seat  of 
actual  disease;  I  allude  to  the  hysterical  breast  of  Astley  Cooper  and  the  hysterical  joint 
of  Brodie.  It  is  not  always  that  the  patient  complains  of  pain,  but  an  exquisite  tenderness 
when  the  part  is  touched. 

Then,  again,  there  is  the  opposite  condition  of  anaesthesia,  where,  owing  generally  to 
some  violent  commotion  of  the  nervous  system,  the  sensorium  is  thrown  into  a  lethargic 
state,  and  the  senses  are  sealed.  A  girl  to  whom  I  was  once  called  received  a  great 
fright,  had  an  hysteric  attack,  and  fell  into  a  state  of  lethargy;  during  this  time  she 
appeared  to  have  lost  altogether  the  sense  of  touch.  The  absence  of  sense  of  pain  whilst 
that  of  touch  remains  I  have  already  referred  to,  and  is  very  commonly  met  with  in 
hysteric  women. 

Now,  besides  this  hypersesthesia  or  oversensitiveness,  our  hysteric  patients  complain 
of  and  suffer  pain.  You  must  not  think,  because  your  patient  is  hysterical  that  she  does 
not  feel  pain,  for  assuredly  the  suffering  of  many  hysteric  women  is  real.  There  has 
been,  and  still  is,  much  controversy  as  to  the  seat  and  cause  of  these  pains.  Are  they 
merely  subjective,  and  due,  as  is  the  hypersesthesia,  to  a  morbid  sensibility  of  the  senso- 
rium, or  have  they  a  local  seat?  and,  if  the  latter,  are  they  situated  in  the  nerve  and 
neuralgic,  or  in  the  muscle  and  myalgic  ?  We  have  had  writers  who  have  contended 
strongly  for  one  view  or  the  other,  but  in  all  probability  both  are  correct.  I  think 
however,  we  are  much  indebted  to  those  physicians,  whom  I  have  before  mentioned, 
who  have  directed  attention  to  the  frequent  existence  of  myalgic  or  myosalgic  pains. 
Thus,  the  pains  in  the  side  and  in  the  head  so  frequently  met  with  are  said  to  be  mus- 
cular, and  more  especially  the  pains  which  occur  in  the  chest  or  abdomen.  Two  good 
cases  of  the  kind  I  now  have  under  my  care  in  Mary  Ward.  The  one  a  young  girl,  who 
lies  in  bed  or  sits  in  a  chair,  leaning  forward,  complaining  of  great  pain  at  the  epigas- 
trium. She  cannot  bear  it  touched,  and  says  she  feels  as  if  a  load  were  oppressing  her, 
and  which  will  presently  suffocate  her.     She  is  sometimes  so  bad  that  her  mother  thinks 


414  PSYCHOLOGICAL   MEDICINE, 

she  will  die,  but  at  the  same  time  she  is  well  developed,  stout,  and  has  apparently  no 
real  disease  upon  her.  The  other  case  is  that  of  a  woman  well  known  to  all  students  on 
account  of  the  trouble  which  she  has  imposed  upon  them.  Before  she  came  under  me 
she  was  in  charge  of  one  of  my  colleagues  for  several  months.  Her  complaint  is  a  most 
excruciating  pain  at  the  left  side  of  the  abdomen,  which  draws  her  double,  and  which 
hitherto  has  not  succumbed  to  the  medicines  which  have  been  taken  in  vast  quantities. 
The  only  relief  she  has  obtained  has  been  by  the  subcutaneous  injections  of  morphia, 
which  have  now  been  practiced  for  many  months.  The  woman  is  in  good  condition, 
and  does  not  look  as  if  she  suffered  from  any  organic  disease.  On  examination  of  the 
abdomen,  the  left  side  is  full,  rather  rigid,  and  highly  sensitive  when  touched.  She 
complains,  w^hen  the  paroxysm  of  pain  is  on,  of  a  most  distressing  bearing  down  and 
irritability  of  the  bladder.  She  stated  that  she  had  passed  blood  in  her  water,  and  thus 
the  case  was  treated  as  one  of  calculus  of  the  kidney  and  ureter.  At  the  present  time 
opinions  are  divided  between  this  diagnosis  and  one  of  hysteria,  where  the  pain  is  due 
to  a  spasm  of  the  abdominal  muscle.  My  own  opinion  inclines  to  the  latter  view,  perhaps 
being  somewhat  prejudiced  by  the  fact  that  the  great  master  Sydenham  takes  such  a  case 
as  illustrative  of  one  of  the  forms  of  hysteria,  and  which  I  will  read :  "  When  this  disease 
seizes  one  of  the  kidneys,  it  plainly  represents,  by  the  pain  it  causes  there,  a  fit  of  the 
stone,  and  not  only  by  that  sort  of  pain  and  by  the  place  it  rages  in,  but  also  by  violent 
vomitings  which  accompany  it,  and  also  for  that  the  pain  sometimes  extends  itself  through 
the  passage  of  the  ureter,  so  that  it  is  very  hard  to  know  whether  these  symptoms  proceed 
from  the  stone  or  from  some  hysterick  diseases,  unless  perchance  some  unlucky  accident 
disturbing  the  woman's  mind  a  little  before  she  was  taken  ill,  or  the  vomiting  up  of  green 
matter,  shows  that  the  symptoms  rather  proceed  from  an  hysterick  disease  than  from  the 
stone.  Neither  is  the  bladder  free  from  this  false  symptom,  for  it  not  only  produces  pain 
there,  but  it  also  stops  the  urine  just  as  if  there  were  a  stone,  whereas  there  is  none.  But 
this  last  kind  seizing  the  bladder  happens  very  seldom,  but  that  which  resembles  the 
stone  in  the  kidneys  is  not  so  rare." 

Then,  besides  hysterical  pains,  we  have  disturbances  of  all  the  various  organs  of  the 
body.  Palpitation  of  the  heart  is  very  frequent.  Then  the  breathing  may  be  affected, 
and  we  have  a  kind  of  nervous  asthma.  The  larynx  may  be  affected ;  at  one  time  there 
is  a  want  of  power  to  articulate,  and  neurophonia  is  one  of  the  commonest  symptoms  of 
the  hysteric  condition.  At  another  time  the  larynx  is  over-sensitive,  and  we  have  that 
troublesome  and  most  annoying  symptom,  the  hysteric  cough.  Some,  however,  have 
considered  this  due  to  a  kind  of  chorea  or  spasm  of  the  diaphragm.  You  may  recognize 
it  by  the  loud  hollow  or  barking  character,  want  of  expectoration,  and  any  evidence  of 
disease  of  the  chest,  or,  to  give  the  description  in  the  words  of  Sydenham,  which  is  both 
precise  and  accurate,  "  sometimes  it  (the  hysteric  disease)  seizes  the  lungs,  and  the  pa- 
tient coughs  almost  without  intermission,  but  expectorates  nothing ;  and,  thoijgh  this  sort 
of  cough  does  not  shake  the  breast  so  violently  as  that  which  is  convulsive,  yet  the  ex- 
plosions are  much  more  frequent." 

Sickness  is  one  of  the  most  troublesome  and  obstinate  of  all  hysteric  disorders,  because 
the  organ,  having  got  into  the  bad  habit  of  discharging  its  contents  upwards,  can  with 
difficulty  be  broken  of  it.  It  is  remarkable  that,  in  these  cases  of  daily  vomiting,  the 
characteristic  of  the  hysteric  condition,  the  plumpness  or  absence  of  emaciation  still  per- 
sists. One  mode  by  which  we  diagnose  such  cases  as  hysteric,  is  that  no  medicine  is 
of  any  avail ;  in  real  disease,  even  in  such  organic  maladies  as  cancer,  our  ordinary  reme- 
dies afford  relief,  but  here  the  cure  must  be  attempted  through  the  nervous  system.  I 
believe  the  best  method  is  to  starve  the  patient  for  a  while,  or  to  use  injections,  so  as  to 


HYSTERIA.  415 

preserve  the  stomach  in  absolute  quiet  for  some  days,  and  then  to  commence  with  the 
smallest  quantities  of  food. 

The  bowels,  again,  are,  to  use  Sydenham's  expression,  seized  upon  by  hysteria.  Thus, 
prolonged  and  obstinate  constipation  is  a  not  uncommon  phase  of  the  disease.  This  is 
only  to  be  cured  by  the  medical  man  having  his  patient  well  in  hand,  and  by  letting  her 
know  that  he  is  quite  aware  of  the  want  of  importance  of  her  malady.  The  regular  plan 
is  for  such  a  patient,  like  others  of  the  kind,  to  be  taken  from  doctor  to  doctor,  who 
write  the  usual  prescriptions,  and  with  the  usual  results.  The  influence,  which  can  be 
produced  on  hysterical  patients  by  physicians  and  attendants,  is  well  seen  by  some  of 
the  cures  which  occur  under  the  direction  of  one  of  our  "  sisters,"  who  introduces  her- 
self to  her  patients  with  "  No  nerves  in  Esther  Ward." 

As  regards  the  nervous  influence  on  the  kidneys  in  the  production  of  a  large  amount 
of  water,  the  fact  is  one  of  importance  in  a  diagnostic. point  of  view.  Sydenham  says: 
"  Among  all  the  symptoms,  which  accompany  the  disease,  this  is  the  most  proper  and 
almost  inseparable — ^^viz.,  a  urine,  as  clear  as  rock-water,  and  this  hysteric  women  evacu- 
ate plentifully,  which  I  find  by  diligent  inquiry  is  in  almost  all  the  pathognomonic  sign 
of  this  disease,  which  we  call  hysteric  in  women,  and  hypochondriac  in  men ;  and  I 
have  sometimes  observed  in  men  that  presently  after  making  water  of  a  citron  color  (yea, 
almost  the  next  moment),  being  suddenly  seized  with  some  violent  perturbation  of  the 
mind,  they  presently  void  water  as  clear  as  crystal,  and  in  great  quantity.  Three  years 
ago,  a  nobleman  sent  for  me,  who  seemed  to  be  suffering  from  an  hypochondriac  colic. 
Visiting  him  one  day,  I  looked  upon  his  urine,  which  was  of  a  citron  color.  He  was  then 
merry  and  cheerful,  and  said  he  had  a  craving  appetite ;  but  one,  coming  in  at  that  very 
moment,  vexed  him  so  much  that  suddenly  being  taken  ill,  he  called  for  a  chamber-pot, 
which  he  almost  filled  with  urine  as  clear  as  crystal." 

Indeed,  if  I  were  to  detail  all  the  disturbances  to  which  the  body  is  liable  in  hysteria, 
I  might  occupy  you  for  a  month,  or,  to  quote  Sydenham  once  more,  *  nor  is  this  disease 
only  frequent,  but  so  strangely  various,  that  it  resembles  almost  all  the  diseases  poor 
mortals  are  inclinable  to.  For,  in  whatever  part  it  seats  itself,  it  presently  produces  such 
symptoms  as  belong  to  it,  and,  unless  the  physician  is  very  skilful,  he  will  be  mistaken, 
and  think  those  symptoms  come  from  some  essential  distemper  of  this  or  that  part,  and 
not  from  any  hysteric  disease."  . 

I  can  scarcely  tell  you  how  to  treat  these  people.  Occupation  and  diversion  for  the 
mind  are,  no  doubt,  the  most  essential  elements  in  any  treatment,  but  they  are  just 
those  which  you  cannot  enforce.  The  worst  part  of  the  therapeutical  system  is  this, 
that,  not  only  will  the  patient  not  take  your  advice,  but  by  prescribing  for  him,  you  are 
assisting  in  perpetuating  his  illness.  You  might  think  that  a  patient,  who  was  always 
ailing  and  got  no  relief,  would  not  trouble  medical  men  any  further,  but  it  is  very  re- 
markable that  it  is  that  very  man  who  takes  our  physic.  He  will  sit  down  and  tell  you 
of  the  number  of  medical  men  he  has  seen,  and  show  you  a  bundle  of  prescriptions,  de- 
claring that  they  have  done  him  no  good,  and  yet  he  will  ask  for  another. 

Case  of  general  hysterical  paralysis  treated  by  the  continuous 
galvanic  current,  under  the  care  of  Dr.  Savage,  at  the  Samaritan  Free 
Hospital,  London : 

An  unmarried  woman,  aged  nineteen,  was  brought  to  the  hospital  by  her  mother  in 
September  last,  to  ask  the  advice  of  Dr.  Savage.  She  had  always  been  in  indifferent 
health,  and  during  the  last  three  years  gradually  lost  the  power  over  her  arms  and  legs 


41 6  PSYCHOLOGICAL   MEDICINE. 

lo  such  an  extent  that  she  is  scarcely  able  to  walk  even  when  supported,  and  entirely 
incapacitated  from  doing  any  work  whatever.  She  first  menstruated  at  fifteen  years  of 
age,  but  has  always  been  very  irregular,  and  the  discharge  verj'pale  and  slight.  Sixteen 
months  ago  the  catamenia  ceased  altogether,  and  from  that  time  she  became  nearly 
idiotic.  At  present  she  is  very  listless,  has  a  vacant  look,  and  considerable  dilatation  of 
both  pupils,  more  especially  of  the  left  one.  The  left  iris  is  scarcely  at  all  influenced  even 
by  a  strong  light.  Her  voice  is  almost  entirely  gone ;  she  can  only  speak  in  a  faint  whisper. 
She  is  frequently  troubled  by  pain  in  the  head  and  the  back.  Her  hands  and  feet  are 
always  quite  cold.  She  complains  of  sickness  in  the  morning,  total  want  of  appetite, 
and  constipated  bowels.  She  has  had  hysterical  (epileptiform)  fits.  She  has  been  under 
medical  treatment  for  a  long  time,  but  without  any  benefit. 

Seeing  this  condition  of  the  patient.  Dr.  Savage  consulted  with  Dr.  Althaus,  with  the 
view  of  applying  some  form  of  galvanic  electricity  in  order  to  rouse  her  nervous  system. 
The  latter  gentleman  made  a  most  careful  examination  of  the  state  of  sensibility  all  over 
the  body,  and  found  that  there  was  nearly  complete  anaesthesia  of  the  whole  left  side, 
including  the  conjunctiva.  On  the  right  side  the  loss  of  sensation  was  not  so  much 
marked  as  on  the  left ;  but  the  prick  of  a  pin  was  only  felt  as  if  it  were  a  touch  by  some 
blunt  instrument,  and  the  examination  by  Weber's  compass-sesthesiometer  did  not  lead 
to  any  results,  as  the  patient  could  nowhere  distinguish  whether  she  was  touched  by  one 
point  or  two.  The  muscles  appeared  to  be  very  badly  nourished,  but  they  contracted 
tolerably  under  the  influence  of  the  electro-magnetic  current. 

In  cases  like  the  foregoing,  the  application  of  the  continuous  galvanic  current,  such  as 
produced  by  a  large  number  of  cells  of  Bunsen's  or  Daniell's  battery,  feebly  charged, 
generally  proves  curative.  It  is  a  matter  of  doubt  whether  the  current  acts  directly  on 
the  spinal  cord,  as  is  asserted  by  Professor  Remak,  or  whether  it  merely  acts  on  the 
nervous  centres  by  reflex  action  from  the  sentient  nerves  of  the  skin.  The  latter  opinion 
is  held  Dr.  Althaus,  who  thinks  that  the  resistance  offered  to  the  passage  of  the  current 
by  the  bones  and  membranes  enveloping  the  nervous  centres  is  too  great  to  be  overcome 
by  a  current  of  such  tension  as  it  is  safe  to  apply  in  the  human  subject.  The  principle 
of  reflex  action,  moreover,  is  quite  sufficient  to  explain  the  physiological  and  therapeu- 
tical action  of  the  continuous  current,  so  that  it  is  not  necessary  to  go  out  of  our  way  and 
assume  principles  of  electric  conduction  for  the  human  body  different  from  those  which 
obtain  for  other  physical  bodies.  However  this  may  be,  thus  much  is  certain — that  the 
continuous  current,  if  applied  in  a  proper  manner,  has  a  distinct  action  on  the  nervous 
centres,  such  as  is  not  possessed  by  the  interrupted  current.  In  cases,  therefore,  where 
the  affection  proceeds  from  a  lesion  of  the  nervous  centres,  the  continuous  current  may 
be  used ;  while  for  local  ailments  invading  peripheral  nerves,  the  interrupted  current  is 
more  beneficial. 

In  the  case  just  mentioned,  a  current  of  from  forty  to  fifty  cells  of  Daniell's  battery 
was  sent  in  an  inverse  direction  to  the  spine,  from  the  nape  of  the  neck  downwards  to 
the  sacrum,  for  ten  minutes.  The  operation  was  repeated  twice  a  week.  The  pain 
caused  by  this  proceeding  is  very  insignificant  in  the  majority  of  cases,  and  to  some  pa- 
tients the  sensation  is  positively  pleasant.  After  six  weeks'  treatment  in  the  way  described, 
the  patient  was  so  much  improved  that  she  could  walk  three  miles  at  a  time  without  sup- 
port; she  could  dress  and  feed  herself;  was  able  to  do  heavy  work  about  the  house; 
had  always  warm  hands  and  feet;  the  voice  had  returned;  the  bowels  acted  regularly; 
and  she  was  cheerful,  and  took  an  interest  in  everything  relating  to  her  affairs.  The 
pupils  now  were  quite  normal.  An  examination  by  means  of  the  aesthesiometer  showed 
that  sensation  had  been  quite  re-established  on  the  left  as  well  as  on  the  right  side.     She 


EPILEPSY.  417 

was  discharged  on  November  19th,  being  then  in  perfect  health,  with  the  exception  of 
the  amenorrhoea,  which  still  persisted,  and  an  occasional  feeling  of  sickness  in  the  morning. 

In  this  case  the  disorder  was  evidently  of  a  merely  functional  character ;  but  cases 
which  are  at  present  under  Dr.  Althaus's  care  seem  to  show  that  even  in  severe  structural 
lesions  of  the  cord  and  its  appendages,  the  continuous  galvanic  current,  if  properly  ap- 
plied, produces  highly  satisfactory  results.  One  of  the  cases  is  that  of  a  girl,  aged 
thirteen,  who  six  years  ago  had  meningitis  spinalis  lumbaris,  contracted  by  sitting  in 
winter  on  a  cold  door-step ;  and  who  having  become  completely  paralyzed  in  the  lower 
extremities,  was  admitted  into  Guy's  Hospital,  under  the  care  of  Dr.  Gull.  She  remained 
in  the  hospital  nine  months,  but  without  in  the  slightest  degree  recovering  the  use  of  her 
limbs.  In  October  last  she  was  sent  to  Dr.  Althaus  by  Dr.  Leared,  under  whose  care  she 
had  been  for  some  time  previously.  When  she  was  first  brought  under  the  influence  of 
the  continuous  current  the  paraplegia  was  complete,  the  patient  being  perfectly  helpless, 
and  the  legs  being  wasted  to  the  last  degree.  She  is  now  so  far  improved  that  she  can 
move  her  legs  in  all  directions;  and  although  she  is  not  yet  able  to  stand  without  support, 
Dr.  Althaus  holds  out  the  expectation  that  by  continuing  the  treatment  she  will  entirely 
recover.  The  bulk  of  the  legs  has  considerably  increased  although  no  local  application  of 
the  current  to  the  legs  has  been  made. 

The  continuous  current  also  proves  beneficial  in  what  has  been  recently  described  as 
"  ataxie  locomotrice  "  by  Duchenne,  but  which  is  nothing  else  than  the  disease  long 
known  to  the  profession  as  atrophy  of  the  posterior  columns  of  the  cord,  and  described 
by  Romberg  as  "  tabes  dorsalis.'' 


CHAPTER  XXI. 


EPILEPSY, 


Epilepsy  is  a  functional  disorder  of  the  nervous  centres,  the  phe- 
nomena of  which  morbid  state  consists  in  seizures,  generally  sudden 
in  their  invasion  ;  preceded,  as  a  rule,  by  a  well  marked  prodromal 
period  ;  characterized  by  loss  of  consciousness  (coming  on  suddenly) 
and  attended  by  peculiar  involuntary  muscular  movements  which 
are  highly  spasmodic  and  convulsive  in  nature. 

Epileptic  paroxysms  may  properly  be  divided  into  three  stages. 
In  the  first  stage  there  is  sudden  and  complete  loss  of  consciousness, 
tonic  contraction  of  the  muscles  all  over  the  body,  those  of  the  face 
and  neck  being  affected  by  spasm  first.  All  the  limbs  are  rigid  and 
all  the  muscles  work  convulsively.  Respiration  is  impeded  or  ar- 
rested, and  with  this  arrest  occurs  a  groan  or  smothered  cry.  Pallor 
of  the  face  occurs,  followed  by  redness  or  duskiness  of  the  surface 

27 


41 8  PSYCHOLOGICAL   MEDICINE. 

of  the  skin,  in  some  cases,  while  in  other  cases,  the  pallor  does  not 
occur  at  all,  duskiness  of  face  being  present  throughout  the  entire 
paroxysm.  The  pupils  are  dilated  at  the  commencement  of  the  at- 
tack. The  pulse  is  usually  small,  and  at  times  imperceptible,  while 
the  carotid  arteries  throb  and  beat  violently.    ' 

In  the  second  stage  the  unconsciousness  continues  and  is  persis- 
tent ;  clonic  spasms  are  almost  universal,  during  which  the  jaws 
are  champed  together  and  the  tongue  is  bitten,  the  breathing  is  la- 
borious and  violent,  and  the  patient  often  foams  at  the  mouth.  In 
the  second  stage,  also,  the  dusky  redness  of  the  surface  increases, 
and  the  pupils  oscillate,  the  pulse  is  throbbing  and  labored,  and  the 
heart  beats  tumultously. 

There  is  a  jaded,  exhausted  state  of  the  whole  system  in  the  third 
stage  of  the  epileptic  fit  and  the  patient  lapses  into  the  after  stage  of 
stupor  and  exhaustion.  There  is  lassitude  and  stupor  with  headache 
for  some  hours  succeeding  a  paroxysm.  Epileptic  paroxysms  may 
occur,  in  which  there  is  loss  of  consciousness  without  evident  spasm. 
There  may  be,  also,  a  loss  of  consciousness  with  local  spasmodic  ac- 
tion. The  cause  of  epilepsy  is  preeminently  hereditary  taint,  by 
which  I  mean  more  particularly,  that  in  tracing  back  the  ancestry  of 
the  patient,  we  shall  almost  inevitably  find  that  there  has  been  an 
hereditary  proclivity  or  predisposition  to  nervous  disease  upon  slight 
exciting  causes.  That,  in  other  words,  there  is  a  family  neurosis 
which  has  manifested  itself  in  various  generations  by  insanity,  phth- 
isis, inebriety  or  idiocy.  Epilepsy,  also,  is  caused  sometimes  by  exces- 
sive mental  anxiety,  to  which  has  been  superadded  a  sudden  fright. 
Epilepsy  appearing  after  the  age  of  2 1  years  is  generally  caused  by 
syphilis,  and  we  treat  the  syphilis  with  large  doses  of  the  iodide  of 
potassium,  with,  perhaps,  mercurials  added,  and  the  epileptic  convul- 
sions disappear.  The  syphilitic  neuroses  are  not  very  rare,  but  are  very 
often  overlooked.  The  centric  causes  of  epilepsy  are  peculiar  forma- 
tions of  the  head,  ossific  particles  in  the  dura  mater,  and  the  develop- 
ment of  tumors.  There  is  no  necessary  relation  existing  between  epi- 
lepsy and  mental  deterioration.  In  a  little  over  one-half  of  my  cases 
of  epilepsy,  I  have  observed  this  deterioration  to  a  greater  or  less  ex- 
tent. 

When  attacks  of  epilepsy  appear  after  puberty,  there  is  probably 
more  danger  to  the  mental  integrity  of  the  patient,  than  when  the 
epilepsy  is  developed  previous  to  that  time.  It  is  difficult  to  state 
with  any  degree  of  accuracy  as  to  the  periodicity  of  epileptic  seizures. 


EPILEPSY.  419 

Most  patients  will  tell  you  that  their  attacks  occur  either  every  day, 
every  week  orevery  month,  and  there  are  a  few  who  say  that  they  never 
know  when  to  expect  an  attack.  In  women,  it  is  not  infrequent  to  see 
the  attack  appearing  at  the  time  of  menstruation.  Epilepsy  may  be 
complicated  with  epileptic  mania.  There  is  generally  no  warning  either 
to  the  patient  or  physician  of  this  very  furious  and  dangerous  form  of' 
mania.  The  history  of  the  two  following  cases  which  occurred  in  my 
practice  serve  to  illustrate  the  general  nature  and  character  of  such 
attacks.  A  lady  of  twenty-five  years  of  age  was  placed  under  my  care 
with  epileptic  mania.  She  had  had  a  great  many  attacks  of  epilepsy 
which  were  preceded  and  followed  by  attacks  of  maniacal  excitement, 
which  rendered  her  a  dangerous  patient.  She  had  been  under  re- 
straint many  times.  About  one  month  after  being  placed  under 
treatment,  she  became  very  noisy  and  excited,  as  was  her  habit  be- 
fore her  fit,  and  threatened  to  kill  her  attendant.  Her  eyes  were 
suffused,  her  mouth  dry,  her  pulse  140,  and  her  tongue  thickly  furred. 
She  was  put  on  one-drachm  doses  fluid  extract  of  ergot,  three  times 
a  day.  After  taking  the  ergot  for  two  days,  she  became  quiet,  and 
the  epileptic  seizure  which  followed  was  very  mild,  as  compared  with 
preceding  ones.  The  ergot  was  continued  and  combined  with  so- 
dium bromide,  the  latter  in  30-grain  doses  thrice  daily,  and  this  com- 
bination administered  steadily  for  some  months.  Since  the  com- 
mencement of  the  treatment,  with  the  exception  of  the  first  attack, 
there  has  been  no  return  of  the  maniacal  excitement.  The  fits  have 
decreased  in  frequency  and  intensity,  and  are  not  followed  as  for- 
merly by  maniacal  excitement. 

The  second  case  was  that  of  a  gentleman  affected  with  epileptic 
mania.  He  was  a  strong  muscular  man  and  had  been  subject  to  ep- 
ileptic fits  for  years.  For  a  period  of  from  a  week  to  two  or  three 
days  preceding  the  fits  he  was  very  furious  and  unmanageable,  and 
required  to  be  restrained.  He  was  also  accustomed  to  have  a  period 
of  maniacal  excitement  following  the  epileptic  seizures,  which  lasted 
for  a  variable  period,  during  which  time  his  pulse  would  range  from 
100  to  120,  and  the  face  would  be  deeply  congested.  He  was  put 
on  one-drachm  doses  of  fluid  extract  of  ergot  with  thirty  grains  of 
bromide  of  sodium  thrice  daily,  and  this  continued  for  a  period  of 
two  months.  The  fits  decreased  in  frequency  and  intensity,  and  the 
maniacal  excitement  entirely  disappeared. 

Diagnosis. — With  regard  to  the  diagnosis  of  epilepsy,  it  is  gener- 
ally very  easy  to  distinguish  between  epileptic  fits  and  other  convul- 


420  PSYCHOLOGICAL    MEDICINE. 

sions.  In  cases  where  epilepsy  is  simulated,  the  entire  absence  of 
dilatation  of  the  pupil  will  serve  to  distinguish  between  the  real 
and  the  feigned  disease.  Attacks  of  syncope  may  sometimes  be  mis- 
taken for  paroxysms  oi  le  petit  mal,  but  in  epilepsy,  the  loss  of  con- 
sciousness is  complete  and  sudden,  the  recovery  is  very  rapid  and 
there  is  no  remembrance  of  the  attack.  These  points  will  enable  the 
young  practitioner  to  distinguish  between  the  two.  We  may  distin- 
guish between  hysterical  epilepsy,  or  convulsions  occurring  in  hys- 
terical women,  characterized  by  epileptiform  paroxysms,  by  the  distor- 
ted features,  bitten  tongue  and  dilated  pupils  of  the  genuine  epileptic 
paroxysm.  The  pupils  in  exceptional  cases  of  epilepsy  are  said  to 
be  contracted.  The  convulsions  of  children  dependent  upon  worms, 
teething  or  indigestion  not  only  can  be  easily  traced  to  these  sources 
of  irritation,  but  they  disappear  upon  the  removal  of  the  exciting 
cause.  They  differ  entirely  from  epilepsy  in  that  the  invasion  is 
not  sudden  and  the  paroxysm  is  much  shorter  in  duration.  There 
is  not  complete  unconsciousness  as  in  epilepsy  and  there  is  no  stupor 
of  any  consequence  after  the  convulsions.  There  may  be  induced  by 
sunstroke  and  intemperance  at  times,  an  epileptiform  neurosis  which 
may  exist  for  a  long  time  in  an  undeveloped  or  masked  form,  and 
this  neurosis  is  very  apt  to  be  connected  with  both  homicidal  and 
suicidal  mania. 

Such  attacks  are  often  noticed  to  occur  periodically  for  some  time 
before  the  access  of  genuine  epilepsy.  I  have  often  witnessed,  in 
cases  under  my  charge,  abortive  or  incomplete  epileptiform  attacks, 
where  there  were  no  convulsions,  and  where  there  was  no  complete 
loss  of  consciousness.  I  have  noticed  in  such  cases  either  a  momen- 
tary terror,  slight  incoherence,  a  gust  of  passion,  or  a  mental  blank, 
the  patient,  perhaps,  stopping  in  the  middle  of  a  sentence.  The  pa- 
tient would  be  himself  again,  quite  unconscious  of  what  had  happened 
to  him.  Accompanying  this  confusion  of  ideas  ;  there  may  be,  as  I 
have  remarked,  instantaneous  impulses,  either  of  a  suicidal  or  a  homi- 
cidal nature.  During  seizures  of  epileptic  vertigo,  persons  may  per- 
form actions  and  even  speak  and  answer  questions  automatically. 
There  are  numerous  examples  in  the  works  of  Hughlings  Jackson^ 
Maudsley,  Russell  Reynolds,  Trousseau  and  Hammond,  proving  that, 
while  in  this  unconscious  state,  persons  can  progress  from  odd  or  ec- 
centric actions  to  deeds  of  violence,  suicide  or  murder,  being  unable 
to  remember  the  circumstances  afterwards,  and  therefore  irresponsi- 
ble for  their  actions.     This  class  of  persons  I  have  always  found  irri- 


EPILEPSY.  421 

table,  easily  excited,  very  emotional,  without  adequate  external  cause, 
easily  losing  their  train  of  thought  and  often  unable  to  collect  or  fix 
their  thoughts. 

Prognosis. — The  prognosis  may  be  considered  unfavorable  when 
the  following  conditions  exist:  i.  When  the  disease  is  of  long  stand- 
ing and  idiopathic.  2.  When  hereditary  taint  is  present.  3.  When 
there  is  decided  mental  failure.  •  4.  Violence  of  fits,  frequency  of  re- 
currence, and  an  increasing  bad  effect  left  behind  fits,  are  all  unfavor- 
able omens.  I  have,  however,  in  some  cases  of  long  standing,  and 
with  frequent  seizures  and  some  mental  failure,  been  agreeably  sur- 
prised in  curing  my  patients  by  putting  them  on  the  strychnia  treat- 
ment, commencing  with  g'gth-grain  doses,  and  using  electricity  in 
the  shape  of  general  faradization.  These  were  anaemic  cases,  in  all 
of  whom  the  bromides  had  been  pushed  to  excess  by  the  family 
physician  with  very  little  appreciable  benefit  to  the  patient.  The 
strychnia  acts,  as  I  shall  show  further  on  under  the  head  of  "  Treat- 
ment," by  keeping  the  vessels  of  the  brain  in  a  state  of  permanent  re- 
laxation, thus  preventing  the  access  of  the  epileptic  paroxysm,  the 
basis  of  ivliich  access  is  a  vascular  tomis  luhich  causes  a  sudden  ance- 
mia  of  the  brain.  Professor  Roberts  Bartholow,  of  Philadelphia, 
has  reported  some  excellent  results  from  the  strychnia  treatment  in 
cases  which  had  resisted  the  bromides,  and  my  own  experience  has 
been  very  satisfactory  and  has  been  employed  by  me  for  several 
years. 

Pathology. — It  seems  to  be  very  probable  that,  owing  to  functional 
disturbance  of  the  vaso-motor  nerves  which  are  distributed  to  the 
cerebral  bloodvessels,  we  have,  during  an  epileptic  paroxysm,  pri- 
marily, the  vascular  tonus  just  referred  to  causing  sudden  anaemia  of 
the  brain,  immediately  followed  by  great  congestion  and  hyperaemia. 
The  whole  motor  tract  of  the  cerebrum  and  also  of  the  spinal  cord  is 
undoubtedly  connected  with  the  production  of  epilepsy,  and  proba- 
bly, also,  the  motor  nuclei  in  the  medulla  oblongata  and  on  the  floor 
of  the  fourth  ventricle,  and  the  corpus  striatum,  as  one  of  the  centres 
of  motion,  is  also  concerned.  Sclerosis  and  atrophy  of  the  ascending 
parietal,  and  foot  of  the  third  frontal  convolutions,  and  of  the  cornu 
ammonis,  have  been  found,  post-mortem,  in  epileptics.  It  is  now  sup- 
posed that,  from  the  part  of  the  body  first  and  principally  affected  by 
convulsive  seizures,  we  can  diagnosticate  with  certainty  the  cortical 
centre  primitively  and  principally  affected.     The  epileptic  paroxysm 


422  PSYCHOLOGICAL    MEDICINE. 

seems  to  consist  of  a  sudden  discharge,  starting  probably  from  a 
limited  region  in  the  nerve-centres,  which,  by  its  action  on  the  sen- 
sorium  destroys  consciousness,  and  by  its  action  on  the  motor  sys- 
tem, produces  perverted  or  arrested  action.  As  to  the  relation  which 
either  the  cerebral  ansemia  or  hypersemia  bear  to  the  paroxysm  of 
epilepsy,  we  are  ignorant  farther  than  I  have  already  stated.  The 
pathology  is  very  obscure  and  very  difficult  to  explain. 

Treatment. — During  the  epileptic  paroxysm  we  can  do  nothing 
but  prevent  our  patient  from  injuring  himself  and  removing  all  pres- 
sure from  the  neck  and  abdomen.  When  the  attack  is  preceded  by 
an  aura  of  sufficient  duration  we  may  avert  a  large  number  of  fits 
by  various  means.  Inhalations  of  nitrate  of  amyl,  chloroform,  or 
ammonia  will  often  cut  short  an  attack ;  or  the  internal  administra- 
tion of  ether,  wine,  or  sal  volatile.  Sometimes  a  ligature  or  garter 
of  blister  applied  betv/eenthe  starting-point  of  the  aura  and  the  trunk 
will  avert  the  paroxysm.  A  patient  under  my  care  who  had  a  warn- 
ing sensation,  lasting  for  some  time,  proceeding  from  the  epigastric 
region,  v/as  in  the  habit  of  drinking  a  large  quantity  of  ice- water, 
and  in  this  way  averted  a  great  many  paroxysms. 

With  regard  to  the  treatment  of  the  general  condition  upon  which 
the  epilepsy  depends,  there  are  innumerable  remedial  measures  which 
have  been  tried  with  more  or  less  success.*  Trousseau  recommends 
the  use  of  belladonna  in  pill  form,  the  patient  taking  ith  of  a  grain 
of  the  extract,  or  in  its  place  a  pill  containing  j-g-gth  of  a  grain  of 
atropine.  During  the  first  month  one  pill  daily  is  to  be  given,  and 
a  pill  per  month  added  until  the  patient  takes  from  five  to  twenty 
pills  daily.  The  pills  are  given  in  the  day  or  at  night,  as  the  fits 
are  diurnal  or  nocturnal.  On  the  principle  that  there  is  over- 
excitement  of  the  central  nervous  system,  sedatives,  and  notably 
the  bromides,  have  been  administered,  and  with  some  success.  In 
some  cases  complete  cure  has  followed  this  treatment,  but  more  often 
a  temporary  arrest  of  the  attacks.  In  cases  of  ordinary  epilepsy, 
where  the  bromides  have  not  been  used,  I  employ  the  following : 

*  Dr.  Powers  of  London,  in  treating  562  cases,  found  that  the  attack  ceased  in  241 
cases  while  under  treatment.  In  266  cases,  improvement,  short  of  arrest,  was  obtained, 
the  fits  being  reduced  to  -^■^,  -j^^,  J^  and  even  to  -„\-^  of  their  frequency  and  severity.  In 
55  cases  but  little  or  no  improvement.  Dr.  J.  Hughes  Bennett  in  treating  41  cases  found 
that  in  22  per  cent  the  paroxysms  were  completely  checked  during  the  whole  time  of 
treatment.  In  92  per  cent  the  seizures  were  either  entirely  arrested  during  the  observa- 
tion or  greatly  modified  in  frequency  and  severity. 


EPILEPSY.  ,      423 

R.     Sodii  bromidi,  .  .  .  .         .  .  ,  .  •  ,1  j 

Ammon.  bromid.,      .  .  .  ,  .         .  .  ,  ^  ss 

Aquse, §  vij 

M. 

One  teaspoonful  contains  15  grains  of  the  bromide,  and  I  order  a 
teaspoonful  thrice  daily,  to  be  gradually  increased  until  brominism, 
as  indicated  by  the  disappearance  of  the  faucial  reflex — the  most 
delicate  sign  of  brominism — is  established.  I  guard  against  the  in- 
jurious effect  of  the  bromides  by  administering  3  grains  of  quinine 
daily,  which  assists  the  efficiency  of  the  bromides  and  wards  off 
anaemia.  Chloral,  in  weak  subjects,  is  preferable  to  the  ammonium 
in  the  anti-epileptic  mixture,  and  may  be  substituted  in  the  same  pro- 
portions. This  formula  was  first  suggested  by  Dr.  Seguin,  of  this 
city,  and  is,  I  think,  quite  an  improvement  on  Brown-Sequard's. 
When  the  fits  are  nocturnal  the  largest  dose  should  be  taken  before 
retiring  and  the  day  doses  proportionately  decreased. 

A  certain  proportion  of  cases  will  improve  under  this  treatment, 
and  be  cured  in  the  course  of  time.  I  do  not  consider  a  case  cured, 
however,  until  at  least  a  year  and  a  half  to  two  years  have  elapsed 
without  the  occurrence  of  a  paroxysm.  In  the  cases  that  apply  to 
me  for  treatment,  or  to  which  I  am  called  in  consultation,  who  have 
taken  the  bromides  to  excess  without  benefit,  and  have  been  rendered 
very  anaemic  by  the  course  of  treatment,  I  commence  with  strychnia 
in  -^-grain  doses,  thrice  daily,  and  gradually  increase  until  physio- 
logical effects  are  produced,  at  the  same  time  using  general  faradi- 
zation, and  I  have  seen  very  rapid  improvement  and  cures  take 
place  under  this  course  of  treatment.  Mental  and  physical  exercise, 
the  latter  especially,  are  of  great  importance  to  the  patient ;  also  a 
regular  plain  diet,  with  little  or  no  meat.  The  patient  should  take 
cold  sponge-baths,  followed  by  friction  with  a  Turkish  towel  or  flesh- 
brush,  and  live  as  much  as  possible  in  the  open  air.  As  I  have  inti- 
mated, I  have  found  the  application  of  electricity  in  the  form  of  the 
induced  current  of  signal  service  in  several  cases,  and  attribute  a 
cure  to  it  combined  with  the  strychnia  treatment  in  three  instances. 
I  also  use  a  pill  containing  yV  of  a  grain  of  phosphide  of  zinc, 
daily  in  each  case,  and  pay  great  attention  to  the  general  health  of 
my  patients. 

One  of  these  cases  was  a  girl  of  twelve  years  of  age,  whose  fits 
occurred  every  few  days.  I  regulated  her  diet,  took  her  out  of 
school,  had  her  take  daily  regular  exercise  in  the  fresh  air,  and  em- 
ployed general  faradization  for  her  daily,  conjoined  with  strychnia 


424      .  PSYCHOLOGICAL   MEDICINE. 

in  ^Q-gra'm  doses,  thrice  daily,  and  phosphide  of  zinc  yV  gr^i^i.  thrice 
daily  in  pill.  Her  fits  soon  began  to  decrease  in  frequency  and  in- 
tensity, and  her  general  health  also  improved.  She  lost  the  dull, 
meaningless  expression  which  had  rendered  her  almost  repulsive, 
and  her  face  took  on  a  bright,  healthy,  happy  expression.  The  fits^ 
after  a  period  of  four  months  ceased  entirely,  and  have  never  reap- 
peared although  five  years  have  elapsed. 

The  second  case  was  that  of  a  man  whose  history  of  himself  was 
so  discouraging  that  I  told  him  at  the  outset  that  I  did  not  expect 
or  hope  to  do  more  than  alleviate  his  symptoms.  His  fits  were  noc- 
turnal, and  he  had  frequent  "  /uny  spe/ls,"  as  he  called  them,  during 
which  he  was  oblivious  to  all  his  surroundings.  The  mental  dete- 
rioration was  very  marked,  and  I  thought  him  a  hopeless  case.  To 
my  utter  surprise  he  began  to  improve  after  a  few  weeks  of  the 
strychnia  and  electricity  treatment,  and  came  to  me  telling  me  with 
great  joy  that  he  had  no  fit  the  preceding  night.  His  wife,  who  oc- 
cupied the  same  room  with  him,  corroborated  his  statement,  and  said 
that  for  the  first  time  in  many  months  he  slept  like  a  child.  The 
treatment  was  kept  up  steadily  for  three  months,  and  at  the  end  of 
that  time  the  fits  had  entirely  ceased,  the  mental  deterioration  had 
disappeared,  and  my  patient  expressed  a  desire  to  resume  his  former 
employment.  I  consented,  but  ordered  him  to  keep  on  the  phos- 
phide of  zinc,  with  strychnia  in  small  doses,  until  ordered  to  stop, 
and  to  report  to  me  weekly.  From  that  day  to  this,  some  three 
years  having  elapsed,  he  has  had  no  recurrence  of  his  fits.  I  do 
not  know  in  how  great  a  proportion  of  cases  such  treatment  would 
avail,  but  I  imagine  in  many,  where  the  bromides  have  proved  ineffi- 
cacious and  where  the  patient  is  weak  and  anaemic. 

As  I  have  intimated,  I  regard  the  basis  of  the  epileptic  attack  to 
be  the  vascular  tonus  which  causes  the  sudden  anaemia  of  the  brain, 
and  in  my  treatment  of  epilepsy,  especially  in  those  cases  where  the 
bromides  have  not  produced  marked  improvement,  but  have  pro- 
duced an  anaemic  condition,  I  am  constantly  obtaining  the  most  grati- 
fying results  from  the  use  of  strychnia,  commencing  with  -g^-grain 
doses.  It  cH7^es  epilepsy  in  connection  with  my  other  treatment,  by 
keeping  the  vessels  of  the  brain  in  a  state  of  permanent  relaxation, 
and  improving  the  nutrition  of  the  brain  and  cord,  and  thus  prevent- 
ing the  sudden  anaemia  of  the  brain  caused  by  the  vascular  tonus.* 

*  Dr.  Wilks  of  Guy's  Hospital,  London,  England,  has  used  with  success  nux  vomica 
and  zinc  and  reported  his  success  in  1S69.     The  author  was  not  aware  of  this  at  the  time, 


EPILEPSY.  425 

Sometimes  the  monobromide  of  camphor,  after  the  failure  of 
most  other  therapeutic  agents,  will  diminish  the  frequency  of  the  re- 
currence of  the  convulsions,  and  in  my  experience  it  diminishes  the 
frequency  of  the  recurrence  of  the  vertiginous  fits  greatly,  and  the 
latter  result  is  very  desirable,  as  I  am  of  opinion  that  the  influenee 
of  epileptic  vertigo  in  inducing  mental  deterioration  is  more  disas- 
trous than  that  of  the  confirmed  malady. 

Dr.  Clouston,  of  England,  some  time  since  made  an  extended 
series  of  experiments  respecting  the  effects  of  bromide  of  potassium 
on  a  number  of  cases  in  his  asylum — the  Cumberland  and  West- 
moreland Asylum — with  the  following  conclusions  : 

"  Twenty-nine  cases  of  epilepsy,  of  old  standing,  all  having  the 
same  diet  and  subject  to  the  same  conditions,  were  subjected  to  sys- 
tematic treatment  by  bromide  of  potassium,  after  their  normal  condi- 
tion as  to  fits,  weight,  temperature,  general  health,  and  mental  state 
had  been  ascertained  and  noted.  Gradually  increasing  doses  of  the 
medicine,  up  to  fifty  grains,  three  times  a  day,  were  given,  and  the 
treatment  was  continued  for  thirty-eight  weeks,  every  particular  in 
regard  to  the  disease  and  their  bodily  and  mental  condition  being 
noted  every  week  during  that  time. 

"  The  total  number  of  fits  taken  by  the  patients  fell  gradually  under 
the  use  of  the  medicine  to  one-sixth  of  their  average  number  without 
medicine. 

"The  fits  during  the  day  were  lessened  to  about  one-twelfth,  and 
those  during  the  night  to  about  one-third  of  the  ordinary  number. 

"  The  reduction  in  the  fits  was  not  uniform  in  all  the  cases.  In 
one  case  it  amounted  to  24  per  cent.,  in  one-half  of  them  to  more 
than  10  per  cent.,  and  in  five  cases  there  was  no  reduction  at  all. 

"  In  one-fourth  of  the  cases  the  fits  were  much  less  severe,  in  some 
being  less  severe  while  as  frequent  as  before. 

"  In  one-fourth  of  the  cases  the  mental  state  was  very  greatly 
improved.  Nervous  and  mental  irritability  and  tendency  to  sudden 
violence  were  wonderfully  diminished  in  those  cases,  and  they  were 
the  worst  of  the  patients  in  that  respect.     Attacks  of  epileptic  mania 

1875,  when  he  first  commenced  to  successfully  use  strychnia  and  zinc  in  combination  to- 
gether with  the  induced  current  of  electricity.  Dr.  Walter  Tyrell,  whose  experience  we 
give,  has  iTsed  strychnia  successfuly  since  1861.  Both  these  observers,  whose  treatment  I 
was  unaware  of  in  1875,  have  therefore  antedated  me  in  the  successful  use  of  strychnia. 
Dr.  Tyrell  thinks  it  acts  by  deadening  the  condition  of  exalted  sensibility  in  the  medulla 
oblongata,  which  Van  der  Kolk  considers  the  predisposing  cause  of  the  disease. 


426  PSYCHOLOGICAL   MEDICINE. 

were  diminished.  In  some  cases  the  mental  state  was  improved, 
while  the  fits  remained  as  frequent  as  ever. 

"  The  majority  of  the  patients  gained  considerably  in  weight  while 
the  doses  were  under  thirty-five  grains  three  times  a  day.  Their 
aggregate  weight  was  greater  at  the  end  of  the  thirty-eight  weeks 
than  it  had  been  to  begin  with,  though  it  began  to  fall  after  thirty- 
five  grain  doses  had  been  reached. 

"  The  temperature  fell  somewhat  until  they  got  up  to  fifty  grain 
doses  thrice  a  day. 

"  The  pulse  gradually  fell  about  seven  beats  up  to  forty  grain  doses, 
after  that  it  rose,  but  not  up  to  its  usual  standard  without  medicine. 

"  None  of  the  patients  suffered  in  their  general  health  except  five, 
all  the  others  were  benefited  in  some  way  except  one. 

"  The  ill  effects  produced  by  the  medicine  in  those  five  cases  were 
torpor  of  mind  and  body,  drowsiness,  increase  of  temperature,  loss 
of  weight,  loss  of  appetite,  and  in  three  of  them  slight  double  pneu- 
monia. 

"  The  cases  most  benefited  by  the  drug  were  very  various  as  to 
the  causes,  number  and  character  of  the  fits,  age,  and  in  every  other 
respect.     On  the  whole,  the  cases  who  took  most  fits  benefited  most. 

"The  cases  in  whom  the  medicine  had  ill  effects  had  all  taken 
fits  from  childhood,  were  all  very  demented  in  mind,  and  took  more 
than  one  fit  per  week,  but  seemed  to  have  nothing  else  in  common. 

"  The  diminution  of  the  fits  and  all  the  other  good  effects  of  the 
medicine  reached  their  maximum,  in  adults,  at  thirty-grain  doses, 
three  times  a  day,  while  ill  effects  were  manifested  when  thirty-five- 
grain  doses,  three  times  a  day,  were  reached.  There  seemed  to  be 
no  seriously  ill  effects  produced  in  twenty  of  the  cases  by  fifty-grain 
doses  of  the  medicine,  thrice  a  day,  continued  for  ten  weeks. 
When  the  medicine  was  entirely  discontinued  in  all  the  cases,  the 
average  number  of  fits  increased  in  five  of  the  cases  benefited,  to  or 
beyond  their  original  number  in  four  weeks  ;  in  thirteen  cases  they 
remained  considerably  less.  The  total  average  during  that  time  was 
a  little  more  than  one-half  the  number  of  fits  which  occurred  in  the 
second  week  after  the  medicine  was  discontinued." 

Dr.  J.  Thompson  Dickinson,  M.A.,  Medical  Superintendent  of  St. 
Luke's  Hospital  says  : 

[A  great  deal  has  been  written  upon  this  interesting  subject,  and  much  has  been  firmly- 
established.     The  first  real  step  in  advancing  our  knowledge  of  the  subject,  was  made 


EPILEPSY.  427 

by  Scbroeder  van  der  Kolk,  whose   researches  were  followed  by  those  of  Brown-Se- 
quard.] 

The  following  are  the  ideas  which  it  is  my  intention  to  attempt  to  establish : 

1.  Epilepsy  is  a  contraction  of  the  cerebral  capillaries  and  small  arterial  vessels ;  the 
order  of  its  stages  in  an  epileptic  attack  being,  irritation  of  brain,  either  direct  or  sec- 
ondary to  exhaustion  ;  contraction  of  cerebral  capillaries  and  small  arterial  vessels ;  cere- 
bral anemia,  and  consequent  loss  of  consciousness. 

2.  The  muscular  contraction  and  spasm,  together  with  all  the  varying  phenomena  as- 
sociated with  epilepsy,  are  altogether  secondary,  and  not  at  all  essential  or  constant,  but 
they  are  all  manifestations  of  imperfect  nervous  (cerebral)  control,  or  a  loss  of  balance 
between  the  nervous  and  other  systems. 

It  is  perhaps  unnecessary  to  prove  loss  of  consciousness  as  the  first  subjective  phe- 
nomenon of  epilepsy,  since  it  is  on  all  hands  admitted;  or,  as  stated  by  Trousseau,  it 
may  be  considered  the  pathognomonic  sign  of  epilepsy.  To  whichever  variety  of  the 
two  great  specific  forms — le  petit mal  ■axiA  le  haut  tiial — any  individual  seizure  may  belong, 
■we  can  always,  by  strict  inquiry,  find  some  amount  of  unconsciousness  in  the  first  stage. 
The  absolute  fixedness  of  this  rule — which  may  almost  be  called  a  law  of  epilepsy — has 
been  doubted,  I  know,  by  few.  I  shall  endeavor  to  meet  their  objections  further  on  in 
this   paper. 

The  condition  of  ansemia  is,  strange  to  say,  the  one  which  was  long  unobserved;  and, 
in  fact,  only  within  the  last  few  years  has  it  been  noticed  at  all.  The  congested  state  of 
the  vessels  of  the  face  and  neck  attendant  upon  epilepsy  is  secondary ;  but  so  much  more 
striking  is  it,  that  for  a  long  time  it  was  the  only  condition  of  vascularity  observed.  The 
pallor  of  epilepsy  is  sometimes  of  considerable  duration  ;  but  this  is  more  particularly  the 
case  in  le  petit  mat,  the  almost  endless  varieties  of  which  were  not  until  lately  recognized 
as  epileptic,  and,  consequently,  as  they  were  considered  as  fainting  attacks,  the  attendant 
pallor  made  no  impression  on  observers ;  usually,  however,  especially  in  le  grand  mal, 
it  is  fleeting.  The  fact  of  pallor,  however,  is  an  indication,  though  not  a  certain  evi- 
dence, of  cerebral  anaemia.  It  would  appear  highly  probable  that  the  face  and  neck  sym- 
pathize with  the  internal  condition  of  the  skull  as  regards  sanguiniference ;  but  further 
evidence  is  necessary,  since,  on  simple  principles  of  animal  mechanics,  if  one  set  of  ves- 
sels be  empty,  another  set  must  be  more  or  less  full ;  and  the  question  might  be  reason- 
ably asked,  why  the  surface-vessels  of  the  head  should  not  be  the  ones  to  take  up  the 
opposite  condition  to  that  of  the  cerebral.  The  question  would,  however,  be  specious, 
since  it  is  the  venous  rather  than  the  arterial  vessels  that  receive  the  blood ;  but  this  is 
not  altogether  absolute.  The  best  evidence  that  the  surface  vessels  correspond  with  those 
of  the  cerebral  is,  that  consciousness  is  lost  during  the  ansemic  state,  while,  in  conditions 
presumably  congestive,  e.  g.,  the  paroxysm  of  whooping-cough,  consciousness  never,  in 
the  true  sense  of  the  expression,  disappears. 

Animals  that  have  died  or  been  killed  during  a  fit  have  always  exhibited  brains  per- 
fectly anaemic,  blanched  and  bloodless.  This  is  borne  witness  to  by  Schroeder  van  der 
Kolk,  Trousseau,  and  Brown-Sequard,  and  has  obtained  in  all  my  own  experiments  and 
observations. 

3.  Whenever  cerebral  anaemia  is  by  any  means  brought  about,  loss  of  consciousness,  is 
the  result;  e.  g.,  if  pressure  be  made  upon  the  brain  or  cerebral  membranes  of  an  animal, 
or  if  the  brain  be  wounded,  anaemia  and  loss  of  consciousness  instantly  result.  In  the 
case  of  an  infant  among  the  out-patients  of  Guy's  Hospital,  said  to  be  epileptic,  I  made 
simple  pressure  with  my  finger  upon  an  open  fontanel,  and  produced  the  whole  of  the 
epileptic  phenomena  perfectly.  An  animal  bled  to  death  passes  through  all  the  stages 
of  epilepsy  before  the  final  struggle.     It  is  hardly  necessary  to  multiply  the  evidence  on 


428  PSYCHOLOGICAL   MEDICINE. 

this  point.  It  is  essential,  however,  to  demonstrate  the  fact  of  the  contraction  of  the  ca- 
pilliaries  and  small  arterial  vessels  as  a  result  of  imtation'or  exhaustion,  as  it  is  to  this 
contraction  that  the  ansemia  and  loss  of  consciousness  are  due. 

Direct  irritation,  such  as  that  already  mentioned,  viz. :  pressure  on  the  membranes  or 
a  wound  of  the  brain,  are  always  followed  by  instantaneous  contraction  of  the  smaller 
cerebral  vessels,  but,  at  the  same  time,  the  capillaries  of  the  medulla  oblongata  become 
distended.  This  point  is  one  particularly  worthy  of  notice,  and  was  first  observed  by 
Schroeder  van  der  Kolk.  If  an  animal  be  trephined,  and  a  knife  plunged  into  his  cere- 
brum, the  whole  of  that  organ  will  become  instantly  ansemic,  and  its  small  vessels  will 
be  found  contracted,  while  those  of  the  medulla — particularly  the  capillaries — will  be 
found  full  and  distended.  It  is  well  to  try  this  experiment  on  an  animal,  the  subject  of 
epilepsy,  as  the  constant  recurrence  of  the  seizures  permanently  dilates  the  capillaries  of 
the  medulla.  It  must  not  be  assumed  from  this  that  the  blood  from  the  cerebral  vessels 
passes  to  the  medulla.  It  is  more  likely  that,  on  account  of  the  sudden  check  to  the  circula- 
tion of  blood  in  the  cerebrum,  the  cumulative  force  of  the  arterial  current  endeavors  to 
expand  itself  in  the  nearest  channels,  of  which  the  medulla  forms  one ;  and  the  absence 
of  resistence,  owing  to  the  yielding  nature  of  its  material,  readily  allows  the  dilatation, 
which  continuously  increases  the  longer  the  epilepsy  is  continued. 

It  thus  is  clear  that,  in  the  relation  of  cause  and  effect,  the  dilation  of  the  capillaries 
must  be  included  under  the  latter  head,  and  must  be  considered  as  altogether  secondary 
to  the  epilepsy. 

As  the  actual  pathological  lesions  associated  with  epilepsy,  I  may  enumerate  tumors 
involving  surface,  surface-abscess,  tuberculous  membranes,  thickened  membranes,  adhe- 
rent membranes,  and  atrophy,  to  which  I  may  add,  as  a  rare,  though  occasional  condi- 
tion, surface-softening,  and  perhaps  softening  of  the  cord.  This  synopsis  is  from  an  ex- 
amination of  the  daily  records  oi post  mo7-fem  examinations  at  Guy's  Hospital,  extending 
over  ten  years;  and  to  it  I  will  add  bony  tumors  projecting  from  the  inner  table  of 
the  skull  and  encroaching  upon  the  surface  of  the  brain ;  also  ossific  membranes. 

Extensive  disease  may  occur  in  the  centre  of  the  brain ;  but  unless  the  surface  be 
involved,  the  central  pathology  will  not  be  associated  with  epilepsy  as  a  concomitant. 

The  histories  of  clinical  cases  give  unequivocal  evidences  of  tumor  and  syphiloma, 
thickening  of  the  cerebral  membranes  from  alchoholism  and  blows,  and  hereditary  trans- 
mission of  both  syphilis  and  nervous  imperfection ;  while  fright  has  sometimes  been  set 
down  as  a  cause.  It  occasionally  happens,  however,  that  the  physician  will  be  baffled 
in  every  attempt  to  find  out  the  particular  predisposing  cause  in  an  individual. 

I  have  already  observed  that  any  cause  which  tends  to  produce  an  ansemic  condition 
of  the  brain  is  sufficient  to  induce  convulsion,  exampled  in  the  sudden  and  direct  deple- 
tion, as  when  an  animal  is  bled  to  death  ;  a  more  gradual  drain,  however,  will  produce 
the  same  result.  For  instance,  menorrhagia  may  stand  in  the  relation  of  cause  to  effect; 
also  watery  conditions  of  the  blood,  as  in  albuminuria,  whether  of  morbus  Brightii  or 
of  parturient  women.  Again,  excess  of  urea,  as  well  as  poisons  directly  introduced  into 
the  blood,  as  atropine,  narcotine,  nicotine,  will  also  stand  in  the  same  relation.  Another 
and  not  uncommon  cause  is  distant  local  hyperemia,  exampled  especially  in  children  who 
suffer  from  convulsive  disease,  as  an  affection  secondary  to  disturbance  of  the  digestive 
organs  and  the  irritation  of  worms;  exemplified  also  in  the  dentition  of  infancy,  but 
in  this  latter  case,  as  perhaps  also  in  a  minor  degree  in  the  former,  the  element  of  pe- 
ripheral irritation  must  be  somewhat  taken  into  account.  Irritation  of  the  peripheral 
extremity  of  a  nerve  will  produce  epilepsy.  A  remarkable  case  was  quoted  by  Dr. 
Brown-Sequard  (reported  by  the  late  Mr.  Standist,  of  Taunton) ;  and  I  have  seen  more 
than  one  case  of  epilepsy  traceable  to  carious  teeth.     The  constant  irritation  of  the  ex- 


EPILEPSY.  429 

tremity  of  a  nerve  exhausts  the  potential  energy  of  the  cells  from  which  the  nerve  takes 
its  rise,  and  produces  a  condition  very  similar  to  shock,  whether  physical  or  psychical. 
All  forms  of  shock  appear  undoubtedly  to  determine  the  occurrence  of  epilepsy  in  some 
individuals;  yet,  with  regard  to  the  psychical  variety,  I  would  speak  very  guardedly. 
One  case  under  my  observation  for  some  time  was  attributed  to  fright !  A  post  mortem 
examination  exhibited  a  surface-tumor.  Another  patient,  the  widow  of  an  officer  who 
was  murdered  before  her  eyes  in  the  Indian  mutiny,  stated  that  she  had  been  epileptic 
ever  since  the  fright  she  received  on  that  heart-rending  occasion.  She  had,  however, 
suffered  from  that  time  up  to  the  time  I  saw  her,  more  or  less  from  menorrhagia. 
The  epilepsy  was  always  increased  when  the  flux  was  augmented,  and  lessened  when 
it  abated.  After  a  short  treatment  directed  towards  the  control  of  the  menstrual  dis- 
charge, the  epilepsy  ceased  to  recur,  and  she  has  remained  free  from  the  attacks  ever 
since. 

Dr.  Brown-Sequard,  in  the  commencement  of  1869,  stated  to  the  French  Academy 
that,  in  continuation  of  his  experiments  in  inducing  epilepsy  by  section  of  the  spinal 
cord,  he  had  concluded  that  the  greater  part  of  the  cord  takes  an  active  part  in  the  pro- 
duction of  convulsion,  because  he  had  seen  attacks  occur  in  the  muscles  innervated  by  a 
segment  of  the  cord  comprised  between  two  sections.  The  fact,  as  stated  by  Dr.  Brown- 
Sequard,  has,  however,  very  little  real  bearing  on  the  subject  of  epilepsy,  except  to  con- 
firm the  truth  of  the  hypothesis  that  the  convulsive  movements  of  epilepsy  are  the  result 
of  loss  of  control. 

Dr.  Brown-Sequard  further  stated  that  the  brain  seemed  to  take  no  part  in  the  convul- 
sion, because  convulsive  seizures  continued  to  be  produced  in  epileptic  guinea-pigs,  in 
which  life  was  maintained  by  artificial  respiration  after  the  brain  had  been  removed. 
This'fact  at  least  tends  to  confirm  the  idea  I  proposed  at  the  commencement  of  this  paper, 
viz. :  that  convulsive  movement  in  epilepsy  is  the  result  of  a  loss  of  cerebral  control,  or  loss 
of  balance  of  control  between  the  cerebral  and  other  systems.  An  animal  with  a  blood- 
less brain — the  effect  either  of  direct  depletion  or  of  irritation  from  any  cause — is  in  very 
much  the  same  condition  as  an  animal  without  a  brain  at  all  j  and,  therefore,  there  is  not 
that  discordance  between  clinical  observation  and  the  results  of  the  experiments  of  Dr. 
Brown-Sequard  which  MM.  Colin,  Ricord,  and  Hardy,  attempted  to  show,  when  Dr. 
Brown-Sequard's  paper  was  discussed.  Dr.  Brown-Sequard  stated  that  he  had  never 
been  able  to  produce  epilepsy  by  unilateral  division  of  the  cord  in  any  animal  other  than 
the  guinea-pig,  except  the  cat.  It  is  a  fact  worthy  of  record  that  I  have  induced  epilepsy 
in  the  rabbit  by  unilateral  section;  I  have  also  seen  one  case  of  epilepsy  in  a  wild  rabbit. 

Dr.  George  Johnson,  Physician  to  King's  College  Hospital,  says  : 

To  what  extent  do  the  phenomena  of  an  epileptic  fit  admit  of  explanation  ?  In  a  fully 
developed  epileptic  fit,  there  are  two  chief  phenomena  to  be  explained ;  these  are  loss  of 
consciousness  and  convulsions.  The  loss  of  consciousness,  until  within  a  very  recent 
period,  has  generally  been  supposed  to  be  a  result  of  congestion  of  the  nervous  centres, 
and  especially  of  the  cerebrum.  But  this  explanation  is  inconsistent  with  the  fact  that 
the  epileptic  loss  of  consciousness  comes  on  in  a  moment  at  the  very  commencement  of 
the  attack,  when  there  is  no  evidence  of  congestion,  and  when  the  face  is  usually  pale 
from  anaemia.  The  congestion  follows  the  loss  of  consciousness,  and  the  explanation  of 
its  occurrence  appears  to  be  this:  The  convulsion  implicates  the  respiratory  muscles; 
the  blood,  therefore,  being  imperfectly  aerated,  is  impeded  in  its  passage  through  the 
lungs;  it  consequently  accumulates  in  the  right  side  of  the  heart  and  in  the  veins.  The 
congestion,  therefore,  is  a  secondary  venous  congestion ;  and,  at  the  time  when  this  con- 


430  PSYCHOLOGICAL    MEDICINE. 

gestion  has  reached  its  greatest  height,  there  is  often  a  commencing  return  of  conscious- 
ness. Obviously,  then,  this  congestion  is  not  the  cause  of  epileptic  loss  of  consciousness. 
This  retrograde  venous  engorgement  is  the  cause  of  the  ecchymoses  beneath  the  skin  and 
the  conjunctiva,  which  often  occur  during  a  fit,  and  of  the  haemorrhage  into  the  substance 
or  upon  the  surface  of  the  brain,  w^hich  happily  is  a  much  less  frequent  accident. 

A  number  of  facts  point  to  the  conclusion,  that  both  the  loss  of  conscious7iess  and  the 
convulsions  of  epilepsy  are  the  result  of  sudden  a7td  extre?ne  a?icE>?tia  of  the  brain. 

In  man,  and  in  most,  if  not  in  all,  warm-blooded  animals,  a  rapid  and  very  copious 
haemorrhage  usually  causes  convulsions.  Kussmaul  and  Tenner  state  ( Ott  Epileptic 
Convulsions  from  Hcemorrhage,  New  Sydenham  Society,  1859)  that,  in  numerous  cases 
of  dogs,  cats,  and  rabbits,  they  observed,  without  a  single  exception,  violent  and  general 
convulsions  preceding  death  from  loss  of  blood.  In  order  to  produce  this  result,  the 
haemorrhage  must  be  rapid.  If  it  occurs  slowly,  so  that  the  vital  powers  are  gradually 
consumed,  death  then  occurs  with  swooning,  drowsiness,  and  delirium,  without  convul- 
sions. 

The  same  observers  found  that  an  interruption  in  the  supply  of  blood  to  the  head  of 
a  rabbit,  by  ligature  or  compi-ession  of  the  arteries,  produces  epileptic  fits  as  surely  as 
haemorrhage  does.  In  about  one  hundred  rabbits,  they  ligatured  or  compressed  the 
carotids  and  subclavians,  from  which,  be  it  remembered,  the  vertebrals  proceed,  and  in 
every  instance,  except  that  of  one  very  old,  lean,  and  feeble  rabbit,  convulsions  occurred. 
In  order  to  produce  convulsions,  it  was  necessary  to  close  all  the  four  arteries  which 
supply  the  brain.  If  but  one  carotid  or  one  subclavian  remained  pervious,  the  animal 
was  enfeebled  and  more  or  less  paralyzed,  but  not  convulsed.  And  again,  if  during  the 
height  of  a  convulsion  the  ligature  is  removed  from  one  carotid,  the  convulsions  generally 
cease  immediately,  and  there  is  a  sudden  change  from  the  most  frightful  spasm  to  com- 
plete relaxation  of  the  muscles.  The  description  of  the  convulsions  thus  artificially  pro- 
duced in  these  animals,  shows  that  they  were  essentially  the  same  as  epileptic  convulsions 
in  the  human  subject.  There  was  the  dilated  pupil,  the  tonic  spasm,  quickly  succeeded 
by  clonic  convulsion,  so  violent  as  to  throw  the  animal  forcibly  forwards  to  a  distance  of 
one  or  two  feet,  and  sometimes  even  over  the  shoulders  of  the  experimenter.  These 
experiments  suffice  to  show  the  fallacy  of  the  explanation  which  Dr.  Brown-Sequard  and 
others  have  given  of  the  clonic  convulsions  in  man.  It  has  been  supposed  that  the  clonic 
convulsions  are  a  consequence  of  the  circulation  of  black  blood  which  results  from  the 
tonic  spasm  of  the  respiratory  muscles.  Now  it  is  manifest  that,  in  these  animals  with 
ligatured  arteries,  no  black  blood  could  reach  their  brain.  In  them,  therefore,  the  clonic 
convulsion,  as  well  as  the  preceding  tonic  spasm,  must  be  due  to  want  of  blood,  and  not 
to  the  altered  quality  of  blood  in  the  brain. 

These  experiments  obviously  cannot  be  repeated  on  the  human  subject;  but  Drs. 
Kussmaul  and  Tenner  describe  the  effects  of  compressing  the  carotids  in  six  men.  In 
all  the  face  turned  pale ;  the  pupils  first  contracted  and  then  dilated ;  the  respiration 
became  slow,  deep,  and  sighing;  then  there  was  giddiness,  staggering,  and  unconscious- 
ness, and  the  patients  would  have  fallen  had  they  not  been  supported.  "  In  two  subjects, 
of  weak  intellect  and  moderately  ansemic,  in  whom,  notwithstanding  the  above  symptoms, 
the  compression  was  continued,  a  choking  sensation,  attended  by  vomiting  and  general 
convulsions,  came  on,  which,  however,  did  not  attain  an  aggravated  form;  for,  on  with- 
holding the  compression,  they  disappeared  in  a  few  seconds."   (  Op.  cit.,  p.  28.) 

Compressing  the  carotids  does  not,  of  course,  entirely  cut  off  the  supply  of  arterial 
blood  to  the  brain;  but  these  experiments  render  it  probable  that  sudden  occlusion  of 
all  the  arteries  of  the  head  will  as  certainly  excite  epileptic  convulsions  in  man  as  in  the 
lower  animals. 


EPILEPSY.  43 1 

There  is  a  class  of  cases  in  which  a  sudden  arrest  of  the  blood  in  its  passage  through 
the  kings  causes  convulsions  and  speedy  death.  I  mean  cases  in  which  the  circulation 
is  arrested  by  the  admission  of  atmospheric  air  into  the  veins — cases  of  embolism  of  the 
pulmonary  artery ;  again,  cases  in  which  the  flow  of  blood  through  the  lungs  is  stopped 
by  the  injection  of  certain  salts  into  the  veins;  and,  lastly,  cases  of  acute  apncea.  When 
animals  are  killed  by  blowing  air  into  the  veins,  the  breathing  becomes  hurried,  the 
animal  falls  down,  and  usually  dies  in  convulsions;  the  contents  of  the  bladder  and  rectum 
being  frequently  expelled  at  the  time  of  death.  Dr.  John  Reid  states  that,  "  in  a  very 
few  cases  only,  is  death  from  this  cause  not  preceded  by  convulsions."  ^Physiological, 
Anatomical,  and  Pathological  Researches.^  The  immediate  cause  of  death  in  these  cases 
is  the  arrest  of  the  frothy  mixture  of  air  and  blood  in  its  passage  through  the  minute 
pulmonary  arteries  (the  air  rarely  reaches  the  left  side  of  the  heart) ;  and,  as  a  result  of 
this  arrest,  there  is,  of  course,  ansemia  of  the  brain  and  of  every  other  organ  supplied  by 
the  systemic  arteries. 

In  man,  it  appears  that  death  from  the  admission  of  atmospheric  air  into  the  veins  has 
been  less  frequently  preceded  by  convulsions.  Probably  the  chief  reason  of  the  less 
frequent  occurrence  of  convulsions  in  the  human  subject  is,  that  the  amount  of  air  acci- 
dentally admitted  is  less,  and  death,  consequently,  is  less  rapid  than  when  air  is  forcibly 
driven  into  the  veins  of  an  animal.  It  would  probably  be  found,  on  a  careful  inquiry, 
that  the  occurrence  of  convulsions  in  tkese  cases  depends  upon  the  circulation  being 
suddenly  and  completely  arrested. 

Convulsions  are  mentioned  in  only  five  out  of  fifteen  cases  collected  by  Amussat ;  but, 
Dr.  Reid  remarks,  "  sevei"al  of  the  cases,  as  we  might  have  expected,  are  very  imperfectly 
reported ;  for  it  is  not  to  be  supposed  that  the  surgeon  or  his  assistants  should  possess  the 
coolness  and  time  to  watch  narrowly  the  phenomena,  when  their  minds  were  agitated  by 
the  threatened  sudden  dissolution  of  their  patient,  and  their  attention  distracted  by  anxious 
attempts  to  save  him."  For  the  same  reason,  the  record  of  cases  of  pulmonary  embolism 
is  very  imperfect;  but,  in  some  instances,  it  has  been  observed  that  death  was  preceded 
by  violent  convulsions ;  and  Virchow  noted,  amongst  the  results  of  artificial  embolism  of 
the  pulmonary  artery  in  animals,  convulsions  and  dilatation  of  the  pupil. —  Des  Einboles 
Pubnonaires.     Par  B.  Ball,  p.  129. 

Again,  Blake  found  that  an  injection  of  a  solution  of  soda  or  its  salts  into  the  veins  of 
a  dog,  destroys  life  by  arresting  the  flow  of  blood  through  the  lungs.  The  left  side  of 
the  heart  is  found  empty  and  the  right  distended.  Death  occurs  in  about  forty-five  sec- 
onds, and  is  preceded  by  violent  opisthotonos. — Edinburgh  Medical  and  Surgical  your- 
nal,  vol.  liv.,  p.  343. 

Blake  attributes  the  nervous  symptoms  to  the  venous  pressure  on  the  brain,  but  they 
may,  with  much  more  reason,  be  attributed  to  the  arrest  of  the  arterial  supply  to  the 
brain.  When,  from  any  cause,  the  blood  is  arrested  in  its  passage  through  the  lungs,  it 
is  obvious  that  distension  of  the  systemic  veins  must  have,  as  its  necessary  correlative, 
comparative  emptiness  of  the  systemic  arteries ;  the  one  will  be  an  index  and  a  measure 
of  the  other. 

Lastly,  we  have  the  convulsions  which  occur  in  almost  every  case  of  acute  apnoea  or 
sudden  suffocation.  It  is  generally  supposed  that  the  convulsions  of  apnoea  are  excited 
by  the  circulation  of  black  blood  through  the  brain,  but  they  are  more  probably  due  to 
the  rapid  and  extreme  anaemia  of  the  brain  consequent  upon  the  impeded  transit  of  blood 
through  the  lungs.  When  the  air  is  excluded  from  the  lungs  the  circulation  is  rapidly 
arrested  by  the  contraction  of  the  minute  pulmonary  arteries.  That  this  is  the  true  ex- 
planation of  the  convulsions  of  apnoea  is  rendered  highly  probable  by  an  observation  of 
Kussmaul  and  Tenner  [op.  cit.,  p.'  75)  to  the  effect  that  "  the  approach  of  convulsions  in 


432  PSYCHOLOGICAL    MEDICINE. 

strangulation  can  be  accelerated  if  the  arteries  are  simultaneously  compressed."  It  is 
obvious  that,  if  the  presence  of  black  blood  in  the  brain  were  the  cause  of  the  convul- 
sions, their  approach  would  be  retarded  and  not  accelerated  by  compression  of  the  arte- 
ries which  supply  the  brain.  The  facts  are  consistent  only  with  the  theory  that  the  im- 
mediate cause  of  the  convulsions  in  cases  of  suffocation  is  a  rapidly  increasing  cerebral 
anjemia,  resulting  from  the  arrest  of  the  pulmonary  circulation.  Black  blood,  in  so  far 
as  it  is  deficient  in  oxygen,  is  equivalent  to  no  blood.  Probably  it  is  rather  by  its  nega- 
tive quality  of  being  unoxygenized  than  by  any  positively  noxious  properties,  that  it  is 
unsuited  to  maintain  the  functions  of  the  brain.  It  is  probable,  too,  that  the  minute 
cerebral  arteries  resist  the  passage  of  black  blood,  and  so  increase  the  anaemia  of  the 
brain.  If  the  circulation  of  dark  blood  through  the  cerebral  vessels  would  excite  con- 
vulsions we  should  expect  to  find  this  symptom  of  common  occurrence  in  cases  of  emphy- 
sema with  bronchitis. 

I  have  now  referred  to  instances  of  epileptiform  convulsions  occurring  under  a  consid- 
erable variety  of  circumstances,  but  all  agreeing  in  this  one  condition,  namely,  that  the 
convulsions  are  associated  with  a  defective  supply  of  arterial  blood  to  the  brain.  Let  us 
now  proceed  to  inquire  whether  the  phenomena  of  epileptic  convulsions,  as  they  ordina- 
rily occur  in  the  human  subject,  are  consistent  with  the  theory  of  ansemia.  It  is  a  matter 
of  general  observation  that,  at  the  very  commencement  of  an  epileptic  fit,  the  face  is  pal- 
lid. There  is  anaemia  of  the  superficial  vessels,  and  with  this  there  is  probably  associated 
anaemia  of  the  intracranial  vessels  which  supply  the  brain  itself.  The  pallor  is,  in  most 
cases,  soon  succeeded  by  lividity,  owing  to  venous  engorgement  consequent  upon  the 
impeded  respiration  and  pulmonaiy  circulation.  It  is  very  remarkable  that,  while  the 
face  is  pallid,  the  heart  and  the  carotids  are  beating  strongly.  It  is  probable,  therefore, 
that  there  exists  some  impediment  to  the  flow  of  blood  through  the  minute  branches  of' 
the  arteries.  To  explain  this  impediment  Kussmaul  and  Tenner  suggest  that  the  minute 
arteries,  both  the  superficial  and  the  intracranial  branches,  contract  so  as  to  bar  the  pas- 
sage of  blood.  Hence  arise  the  pallor  of  the  face  and  the  epileptic  convulsion.  In  some 
cases  it  is  said  that  the  face  is  more  or  less  livid  at  the  very  commencement  of  the  fit. 
The  probable  explanation  of  this  is  that  the  respiratory  muscles  are  convulsed  and  there 
is  a  consequent  venous  turgescence  before  the  spasm  affects  the  facial  arteries.  The 
spasm  of  the  facial  arteries,  though  usually  present,  is  obviously  not  the  cause  of  the  fit. 
The  early  implication  of  the  respiratory  muscles  is  clearly  shown  in  those  cases  in 
which  the  "epileptic  cry" — a  result  of  spasm  of  the  glottis — is  the  first  indication  of 
the  fit. 

Kussmaul  and  Tenner  endeavored  to  support  the  theory  of  arterial  spasm  by  experi- 
ment, and  to  some  extent  they  succeeded.  In  each  of  three  white  rabbits  they  ligatured 
the  two  subclavians  and  one  carotid ;  the  cervical  sympathetic  was  then  exposed  and 
galvanized,  with  a  view  to  excite  contraction  of  the  arteries  by  the  stimulus  conveyed 
through  the  vaso-motor  nerves.  In  two  animals  no  effect  was  produced,  but  in  the  third 
rabbit  the  background  of  the  eye  became  completely  pale,  the  pupil  dilated  so  that  the 
iris  could  scarcely  be  seen,  the  neck  was  drawn  back,  and  violent  convulsions  occurred. 
The  electrodes  being  removed,  the  spasm  ceased,  the  pupil  contracted,  and  the  back- 
ground of  the  eye  became  red,  but  the  animal  continued  in  a  swooning  condition.  After 
some  minutes  electricity,  applied  to  the  sympathetic  nerve,  produced  the  same  effects  as 
at  first.     A  third  attempt  did  not  succeed. 

The  authors  suggest  that  these  experiments  deserve  repetition,  with  the  view  of  ren- 
dering certain  what  at  present  is  probable,  namely,  "  epileptic  convulsions  can  be  brought 
about  by  contraction  of  the  bloodvessels  induced  by  the  vaso-motor  nerves." 

According  to  this  theory,  then,  epilepsy  is  a  result  of  sudden  ansemia  of  the  brain ;  and 


EPILEPSY.  433 

this  ansemia,  when  not  caused  by  haemorrhage  or  by  a  mechanical  impediment  to  the  cir- 
culation outside  the  cranium,  is  due  to  an  extreme  contraction  of  the  minute  cerebral 
arteries.  With  reference  to  this  theoiy  of  arterial  contraction,  all  cases  of  epilepsy  may 
be  arranged  in  two  distinct  classes:  i.  C'ases  in  which  the  arterial  contraction  is  the 
result  of  a  purely  nervous  or  reflex  influence.  2.  Cases  in  which  the  arterial  spasm  is  a 
result  of  blood-poisoning. 

In  the  first  class  are  included  all  cases  of  epilepsy  which  are  due  to  emotional  influence, 
sudden  terror,  or  anger,  or  long-continued  anxiety  and  sorrow,  perpetuated  and  intensi- 
fied often  by  nocturnal  dreams,  and  frequently  recurring  nightmare;  also  cases  associated 
with  those  disordered  states  of  the  nervous  system  which  are  the  result  of  vicious  sensual 
habits ;  cases,  too,  in  which  the  disease  is  hereditary.  This  class  also  includes  cases  of 
epileptic  convulsions  from  the  irritation  of  the  gums  during  dentition ;  of  the  kidney,  or 
the  ureter,  or  the  gall  duct  by  a  calculus ;  and  of  the  alimentary  canal  by  worms.  Again, 
the  cases  in  which  convulsions  result  from  tumors  or  other  organic  disease  of  the  brain 
are  included  under  the  head  of  epilepsy  from  a  reflex  influence.  The  structural  change 
in  the  brain  is  not  the  proximate  cause  of  the  epilepsy;  it  excites  the  epileptic  convul- 
sions through  a  secondary  reflex  influence  upon  the  bloodvessels.  Dr.  Brown-Sequard's 
guinea-pigs,  rendered  epileptic  by  injury  to  the  spinal  cord,  are  also  included  in  this  class 
of  cases.  The  injury  to  the  cord  probably  acts  by  increasing  the  reflex  excitability  of  the 
nervous  centres,  so  that  a  trifling  external  irritation  suffices  to  excite  a  fit. 

In  the  class  of  toxsemic  epilepsy  are  included  those  cases  in  which  noxious  materials  in 
the  blood  are  the  immediate  exciting  cause  of  the  arterial  spasm — ursemic  convulsions 
and  all  cases  of  convulsions  from  retained  excreta;  convulsions  resulting  from  the  ad- 
mission into  the  circulating  blood  of  unwholesome  and  undigested  food ;  the  convulsions 
which  result  from  alcoholism ;  the  convulsions  which  sometimes  occur  during  the  initia- 
tory stage  of  certain  of  the  acute  febrile  exanthemata,  more  especially  small-pox;  the 
convulsions  which  are  occasionally  associated  with  pyjemic  infection ;  and  the  convul- 
sions resulting  from  a  poisonous  dose  of  prussic  acid.  In  each  and  all  of  these  cases  it 
is  probable  that  the  immediate  cause  of  the  convulsion  is  anaemia  of  the  brain,  resulting 
from  contraction  of  the  cerebral  arteries,  the  arterial  spasm  being  excited  by  the  presence 
of  morbid  blood  in  the  vessels. 

In  the  hypertrophy  of  the  muscular  walls  of  the  arteries  of  the  pia  mater,  which  we 
have  recently  observed  in  cases  of  Bright's  disease,  we  have  evidence  of  a  continual 
resistance  to  the  passage  of  the  deteriorated  blood  through  these  vessels.  This  resistance 
probably  explains  some  of  the  cerebral  symptoms  of  Bright's  disease,  but  a  convulsive 
seizure  must  be  due  to  a  sudden  temporary  increase  of  arterial  contraction — this  sudden 
contraction  differing  as  much  from  the  continuous  tonic  contraction  of  the  vessels  as  the 
cardiac  spasm  of  angina  pectoris  differs  from  the  regular  strong  contractions  of  a  hyper- 
trophied  ventricle.  With  reference  to  the  action  of  prussic  acid  upon  the  bloodvessels, 
it  is  noteworthy  that  Blake,  having  killed  a  dog  by  injecting  prussic  acid  into  the  jugular 
vein,  observed  that,  after  the  animal  had  ceased  to  struggle,  the  dynamometer  in  the 
femoral  artery  still  indicated  a  considerable  increase  of  pressure.  This  fact  is  explicable 
only  on  the  supposition  that  the  prussic  acid  excited  unusual  contractions  in  the  minute 
systemic  arteries;  and  this  contraction  of  the  cerebral  arteries  would  account  for  the  con- 
vulsions in  cases  of  prussic  acid  poisoning.  Again,  the  symptoms  which  result  from  an 
over-medicinal  dose  of  prussic  acid  are  such  as  might  be  occasioned  by  a  less  degree  of 
obstruction  to  the  cerebral  circulation.  These  symptoms,  as  described  by  Pereira,  are 
the  following:  "  Disordered  and  laborious  respiration  (sometimes  quick,  at  others  slow 
and  deep),  pain  in  the  head,  giddiness,  obscured  vision,  and  sleepiness.  In  some  instances 
faintness  is  experienced."     These  symptoms  are  remarkably  like  those  of  the  epileptic 

28 


434  PSYCHOLOGICAL   MEDICINE. 

vertigo,  ox  petit  mal,  as  it  is  called,  and,  like  them,  they  are  probably  due  to  a  temporar}' 
and  partial  interruption  of  the  cerebral  circulation  by  arterial  spasm.  The  poison,  being 
very  volatile,  is  quickly  exhaled  by  the  lungs,  and  the  symptoms  soon  cease.  In  accord- 
ance, then,  with  this  theory  of  arterial  contraction,  epilepsy  might  be  designated  cerebral 
collapse ;  and,  on  the  other  hand,  the  arrest  of  the  circulation  by  the  contraction  of  the 
pulmonary  arteries  in  the  collapse  of  cholera  may  be  looked  upon  as  a  form  oi pulmottaty 
epilepsy.  Without  doubt,  the  true  key  to  the  pathology  of  both  these  awful  diseases — 
epilepsy  and  cholera — is  to  be  found  in  this  doctrine  of  arterial  spasm. 

The  two  classes  of  epileptic  cases— the  purely  ner%'Ous  and  the  toxsemic — have  their 
analogues  in  the  two  varieties  of  larj'ngeal  spasm.  Spasm  of  the  larynx  may  result  from 
irritation  of  the  brain,  or  of  the  gums,  or  of  the  alimentary  canal ;  in  short,  it  may  be  a 
purely  nervous  reflex  laryngismus  stridichis,  which  is  closely  allied  to  epilepsy.  On  the 
other  hand,  laryngeal  spasm  may  be  excited  by  a  crumb  of  bread  or  a  grain  of  salt,  or 
other  irritant,  within  the  larynx;  and  this  is  analogous  to  the  arterial  spasm  which  is 
excited  by  toxsemia,  and  which  may  result  in  an  epileptic  fit. 

There  are  various  forms  of  what  may  be  called  partial  epilepsy :  sudden  and  transient 
impairment  of  motor  power,  or  irregular  spasmodic  movements  limited  to  a  particular  set 
of  muscles;  various  disordered  sensations  in  limited  portions  of  the  skin;  derangements 
of  the  special  senses ;  sudden  perversion  of  taste,  or  snrell,  or  sight,  or  hearing ;  sudden 
impairment  of  speech  ;  vertigo;  confusion  of  thought ;  temporary  delirium;  and  mental 
excitement.  One  or  more  of  these  symptoms  may  occur  singly  or  variously  combined  in 
different  cases,  the  onset  and  the  departure  being  often  equally  sudden.  In  explanation 
of  these  phenomena.  Dr.  Hughlings  Jackson  has,  with  much  ingenuity,  suggested  that 
they  may  result  from  a  sudden  temporary  interruption  of  the  blood-current  through  one 
or  more  branches  of  the  cerebral  arteries  by  spasm  of  their  muscular  walls ;  so  that  the 
brain-tissue,  within  a  circumscribed  "  arterial  region,"  having  its  nutritive  supply  arrested 
or  limited,  would  suff"er  a  suspension  or  impairment  of  its  proper  functions.  This  appears 
to  be  a  very  probable  explanation  of  the  curious  phenomena  in  question.  It  must  be 
borne  in  mind,  that  the  brain  is  not  one  organ,  having  a  simple  function,  like  a  lung  or 
a  kidney;  but  that  it  is  a  congeries  of  complex  organs,  having  very  diverse  functions. 
It  seems  probable  that  the  physiological  co-operation  of  all  these  cerebral  organs  may 
require  that  the  blood-supply  to  the  various  regions  of  the  brain  should  be  specially 
regulated  by  certain  branches  of  the  arterial  tree,  under  the  guidance  of  the  vaso-motor 
nerves ;  and  this  regulating  power  residing  in  the  arteries  properly  renders  them  liable 
to  disorderly  action  under  the  disturbing  influences  of  disease. 

It  is  not  now  my  intention  to  enter  into  details  as  to  the  treatment  of  epilepsy;  but 
there  are  two  remedies  upon  which  I  desire  to  say  a  few  words,  namely,  chloroform  and 
bromide  of  potassium.  It  is  a  well-known  fact  that  chloroform  inhalation  has  a  remark- 
able power  of  arresting  epileptic  convulsions.  Its  action  in  warding  off"  a  threatened  fit, 
and  in  cutting  short  a  violent  and  prolonged  paroxysm,  is  uniform  and  certain;  as  uniform 
and  as  certain  as  the  influence  of  sudden  and  extreme  anaemia  in  exciting  convulsions. 
I  for  a  time  supposed  that  the  chloroform  acts  by  relaxing  the  cerebral  arteries ;  Kuss- 
maul  and  Tenner  have  shown  that  animals,  when  etherized,  get  no  convulsions  while 
being  rapidly  bled  to  death,  or  when  their  arteries  are  ligatured.  It  is  probable,  there- 
fore, that  an?esthetic  vapors  prevent  or  stop  convulsions  by  lessening  the  leflex  excitability 
of  the  nervous  system,  so  that  convulsions  do  not  occur  in  etherized  rabbits,  even  though 
the  brain  be  rendered  extremely  anfemic  by  haemorrhage  or  by  arterial  obstruction. 

Recent  experience  has  amply  proved  that  the  bromide  of  potassium,  in  full  and  frequent 
doses  and  sufficiently  long  continued,  is  of  great  value  in  the  treatment  of  epilepsy.  The 
known  physiological  action  of  this  medicine  renders  it  probable  that  its  curative  effect  in 


EPILEPSY.  435 

epilepsy  is  a  result  of  its  soothing,  sedative,  anaesthetic  influence  upon  the  nervous  centres, 
whose  reflex  excitability  it  lessens.  In  short,  its  action  in  jDreventing  convulsions  is 
analogous  to  that  of  chloroform,  differing  in  being  less  powerful  and  rapid  in  its  opera- 
tion, yet,  by  frequent  repetition,  its  influence  may  be  rendered  more  durable  and  more 
permanently  beneficial. 

On  the  treatment  of  epilepsy,  Dr.  Samuel  Wilks,  Physician  to 
Guy's  Hospital,  says: 

As  regards  the  treatment  of  epilepsy,  it  must  be  considered  entirely  empirical.  The 
term  rational  can  scarcely  be  introduced  even  in  the  minor  questions  of  diet,  air,  etc.  I 
have  certainly  known  patients  reduce  their  amount  of  food  and  drink,  especially  in  the 
article  of  meat,  and  with  a  corresponding  diminution  in  the  number  and  severity  of  fits ; 
but,  on  the  other  hand,  1  know  other  cases  where  a  generous  diet  has  been  equally  neces- 
sitated. It  is  just  one  of  those  cases  where  particular  drugs  may  be  of  service,  and  beyond 
their  administration  we  can  do  little.  If  any  old  woman  had  the  possession  of  an  herb 
or  a  salt  which  could  antagonize  the  disease,  her  knowledge  would  be  worth  more  than 
that  of  the  whole  College  of  Physicians,  I  am  happy  to  say  that  this  does  not  apply  to 
many  other  diseases,  where  the  knowledge  you  have  acquired  of  their  nature  will  serve 
you  far  more  than  all  the  medicines  in  the  Pharmacopoeia.  The  remedies,  then,  ai'e 
empirical ;  those  that  have  hitherto  been  most  in  vogue  have  been  the  metallic  tonics. 
It  is  remarkable  that  such  class  of  drugs  seemrs  to  have  more  efficiency  in  morbid  states 
of  the  nervous  system  than  those  which  have  a  more  direct  physiological  effect.  In  the 
whole  range  of  nervous  affections  you  will  find  this  to  be  the  case.  In  my  own  experi- 
ence, the  only  remedies  of  this  kind  M-hich  I  have  seen  useful  have  been  belladonna  and 
nux  vomica — ^drugs  having  different  physiological  actions.  I  have  had  cases  where  both 
remedies  have  been  apparently  beneficial.  The  metals  have  been  used  with  a  certain 
amount  of  success  from  time  immemorial,  such  as  arsenic,  silver,  iron,  and  zinc.  Some 
years  ago  I  used  all  these  remedies  largely  amongst  the  out-patients,  and  should  certainly 
give  the  preference  to  zinc;  I  know  now  more  than  one  case  of  epilepsy  where  the  patient 
is  always  better  on  the  resumption  of  this  remedy.  If  you  suspect  any  local  cause  in 
the  brain,  you  may  adopt  other  measures ;  thus  I  have  seen  a  case  apparently  cured  by 
mercury.  Those  which  were  benefited  by  iodide  of  potassium  had  no  doubt  a  syphilitic 
origin. 

It  was  whilst  I  was  examining  the  effects  of  the  various  remedies  that  I  discovered  the 
very  superior  value  of  the  bromide  of  potassium.  I  was  at  that  time  trying  this  remedy 
against  the  iodide  in  bronchocele  and  some  other  disorders,  and  being  in  the  habit  of 
often  using  the  iodide  in  epilepsy,  I  substituted  the  bromide  for  it.  I  was  at  first  under 
the  impression  that  it  was  acting  as  an  absorbent,  and  was  picking  out  for  its  operation 
those  cases  where  the  disease  had  a  syphilitic  or  local  origin;  but  when  the  cures  came 
to  be  numerous,  the  explanation  would  not  apply,  and  it  was  evident  that  a  very  valuable 
specific  remedy  had  been  obtained.  Various  writers  had  certainly  mentioned  the  drug 
with  a  host  of  others,  but  only  to  again  lay  it  on  the  shelf  with  them.  I  was  not  aware 
at  that  time  that  Sir  C.  Locock  had  recom.mended  its  use,  for  it  does  not  appear  that  his 
observations  had  been  specially  brought  before  the  profession,  much  less  been  confirmed 
by  others.  As  far  as  I  know,  it  was  when  Sir  C.  Locock  was  President  of  the  Royal 
Medical  and  Chirurgical  Society,  on  the  occasion  of  Dr.  Sieveking  reading  a  paper 
on  epilepsy,  that  he  made  the  following  remarks,  and  which  I  quote  from  the  Lancet 
of  May,  1857:  "Some  years  since  he  had  read  in  the  British  and  Foreign  Medical 
Review  an  account  of  some  experiments  performed  by  a  German  on  himself  with  bromide 


43^  PSYCHOLOGICAL    MEDICINE. 

of  potassium.  The  experimenter  had  found  that  when  he  took  ten  grains  of  the  pi-epara- 
tion  three  times  a  day  for  fourteen  days,  it  produced  temporary  impotency,  the  virile 
powers  returning  after  leaving  off  the  medicine.  He  (Dr.  Locock)  determined  to  try 
this  remedy  in  cases  of  hysteria  in  young  women  unaccompanied  by  epilepsy.  He  had 
found  it,  in  doses  of  from  five  to  ten  grains  three  times  a  day,  of  the  greatest  service.  In 
a  case  of  hysterical  epilepsy,  which  had  occurred  every  month  for  nine  years,  and  had 
resisted  every  kind  of  treatment,  he  had  administered  the  bromide  of  potassium.  He 
commenced  this  treatment  about  fourteen  months  since.  For  three  months  he  gave  ten 
grains  of  the  potassium  three  times  a  day.  He  then  reduced  the  amount,  and  the  patient 
had  no  epilepsy  since  the  commencement  of  the  potassium.  Out  of  fourteen  or  fifteen 
cases  treated  by  this  medicine,  only  one-half  had  failed."  It  was  in  the  early  part  of 
i860  that  I  commenced  to  use  it;  in  the  following  year  about  a  dozen  cases  were  pub- 
lished in  the  Medical  Times  and  Gasette,  being  the  first  series  of  cases  systematically 
described  (that  I  can  find)  in  which  the  remedy  had  been  found  eminently  successful. 
It  was  thus  evident  that  the  bromide  was  not  simply  supplanting  the  iodide  in  the  cure 
of  some  special  form  of  the  complaint,  but  that  the  drug  had  some  remarkable  influence 
over  the  pure  and  simple  form  of  epilepsy.  This  has  now  been  confirmed  by  others,  and 
even  by  those  who  had  previously  merely  administered  the  bromide,  as  they  had  done 
many  other  remedies,  without  sufficient  trial,  and  had  discarded  it.  Of  course,  like  every 
other  remedy,  its  success  has  been  overrated,  and  thus  the  disappointment  which  natur- 
ally accompanied  the  reaction  of  opinion,  more  especially  when  it  was  employed  for 
almost  every  disease  in  the  nosology.  As  regards  drugs,  then,  I  should  say  that  zinc 
and  the  bromide  are  the  most  important;  but  you  will  have  no  lack  of  opportunity  of 
trying  the  effects  of  remedies,  for  epileptics  often  insist  on  being  physicked  year  after  year 
when  absolutely  nothing  is  being  done  for  them. 

I  ought  to  mention  the  occasional  value  of  counter-irritants  to  the  back  of  the  neck, 
and  of  setons.  I  well  remember  two  men  who  some  years  ago  attended  at  the  hospital, 
and  whilst  tlie  seton  was  open  the  fits  were  absent ;  when  this  dried  up  they  returned.  I 
have  seen  other  cases  of  the  kind  since  this  time.  I  have  already  mentioned  the  case  of 
a  man  whose  life  was  saved  by  bleeding.  I  do  not  know  that  it  is  a  remedy  against  the 
disease,  but  that  it  acts  in  the  most  beneficial  manner  if  the  paroxysm  is  long  continued  I 
have  no  doubt.  In  the  case  I  referred  to,  the  man  had  had  a  succession  of  fits  for  some 
hours,  had  swallowed  nothing,  and  must  shortly  have  died  from  congestion  of  the  lungs, 
had  not  the  lancet  relieved  his  circulation  and  almost  immediately  restored  him  to  con- 
sciousness. I  think  it  very  probable  that  in  those  cases  in  former  times  which  were  con- 
sidered apoplectic,  and  in  which  recovery  rapidly  took  place  after  bleeding,  epilepsy  was 
the  real  disease.  I  am  convinced  that  I  have  seen  several  such,  and  therefore  think  they 
cannot  be  uncommon.  A  man,  for  example,  is  seized  with  a  fit;  you  are  called  to  him, 
and  find  him  comatose,  with  stertor  and  apparent  paralysis  of  one  side ;  you  consider  it 
to  be  a  case  of  apoplexy,  and  recommend  bleeding ;  he  soon  afterwards  recovers  his 
consciousness,  and  after  a  few  hours  the  weakness  of  the  limb  has  passed,  and  the  pa- 
tient is  comparatively  well.  Whatever  the  diagnosis,  the  remedy  has  succeeded,  and  thus, 
in  a  severe  fit  of  epilepsy  which  becomes  protracted,  I  have  no  hesitation  at  all  in  recom- 
mending you  to  open  a  vein.  It  might  appear  strange,  after  declaring  that  an  epilepti- 
form fit  may  be  induced  by  loss  of  blood,  immediately  to  recommend  venesection  as  a 
remedy,  but  it  does  not  folldw  that  the  theory  and  the  treatment  are  antagonistic,  for 
whatever  may  be  the  immediate  cause  of  the  seizure  the  result  is  a  spasm  of  the  chest, 
which,  ending  in  congestion  of  the  lungs,  is  best  relieved  by  liberating  the  blood  from 
the  overcharged  venous  system. 

I  ought  not  to  forget  to  mention  the  remarkable  circumstance  of  our  capability  of  arrest- 


EPILEPSY.  437 

ing  the  attack  by  acting  on  the  spot  whence  the  aura  proceeds.  If  the  attacks  were  due 
to  an  irritation  reflected  from  one  spot,  then  the  removal  of  this  cause  would  stop  the  fit, 
as  in  the  case  of  the  child  I  mentioned,  whose  father  assured  me  that  the  application  of 
laudanum  to  a  sore  spot  on  the  face  would  arrest  or  mitigate  the  paroxysm.  But  when 
the  sensation  on  the  surface  is  altogether  subjective,  a  great  difficulty  in  the  explanation 
arises;  unless  we  are  content  with  supposing  that  as  one  portion  of  the  brain  must  be 
more  especially  involved  in  order  for  the  sensation  to  be  felt  in  one  part  of  the  body 
rather  than  another,  so  some  external  application  to  that  part  may  cause  a  corresponding 
reflection  backwards,  and  arrest  the  process  that  had  already  commenced. 

Dr.  Walter  Tyrell,  in  treating  epilepsy  by  strychnia,  gives  a  case 
as  follows : 

A.  C,  aged  eighteen,  a  girl  of  dull  complexion  and  low  nervous  temperament,  has 
suffered  from  epileptic  attacks  from  eight  years  of  age,  but  much  more  severely  since  the 
appearance  of  the  catamenia,  which  have  been  irregular.  During  the  past  two  years  the 
attacks  have  recurred  every  four  or  five  days  and  oftener  at  the  menstrual  period.  They 
are  violently  convulsive,  but  are  not  preceded  by  any  aura  or  other  warning.  Her  memory 
is  much  impaired,  and  she  suffers  from  almost  continual  headache.  I  here  commenced 
with  Jjjth  grain  of  strychnia,  and  it  was  only  necessary  to  increase  it  to  j^-jjth,  as  the  good 
effects  were  at  once  perceptible  in  an  improved  state  of  health,  regularity  of  the  uterine 
functions,  and  an  entire  cessation  of  the  fits ;  in  fact,  only  two,  and  those  at  intervals  of 
fourteen  days,  have  occurred  since  she  first  commenced  the  medicine,  and  she  has  now 
been  perfectly  free  for  five  months.  In  this  case  also,  cold  bathing,  walking  exercise,  and 
early  rising  were  made  adjuncts  to  the  treatment.  Both  in  this  and  the  following  case 
the  reason  of  the  rapid  success  of  a  comparatively  small  dose  is  that  the  predisposing 
cause  of  the  attacks  was  but  slight,  and  that  consequently  an  increase  of  nervous  power 
being  supplied  to  the  medulla  oblongata  enabled  it  not  only  to  restrain  the  irregular  dis- 
charge of  nervous  power,  but  also  to  restore  the  healthy  functions  of  the  uterus. 

A.  B.,  aged  twenty-three,  a  dull,  phlegmatic  looking  girl,  with  low,  retreating  fore- 
head, has  been  the  subject  of  epileptic  attacks  for  eight  years;  but  latterly  they  have 
become  much  more  severe  in  all  their  characteristics.  The  catamenia  have  never  been 
regular.  In  this  case  I  commenced  with  ^oth  of  a  grain  of  strychnia,  which  dose  she 
continued  to  take  for  nearly  two  months,  when  it  was  increased  to  ifh.  Under  this  (in 
combination  with  cold  affusion  and  outdoor  exercise)  her  health  rapidly  improved,  and 
the  attacks  to  which  she  was  subject  about  every  ten  days,  decreased  both  in  number 
and  severity.  She  has  now  been  entirely  free  from  attack  for  more  than  four  months,  and 
has  discontinued  the  medicine  for  nearly  half  of  that  time. 

I  have  now  been  watching  the  effects  of  strychnia  upon  various  forms  of  epilepsy  since 
i86i,  and  I  have  no  hesitation  in  affirming,  that  in  a  large  majority  of  cases  its  effect  is 
most  beneficial;  at  the  same  time,  I  would  not  be  at  all  understood  to  vaunt  it  as  spe- 
cific, per  se,  in  all  cases.  I  think  that  its  value  lies  in  the  effect  it  has  in  deadening  that 
condition  of  "exalted  sensibility"  and  activity  of  the  medulla  oblongata  which  Van  der 
Kolk  (and,  I  imagine,  most  recent  authors)  considers  the  predisposing  cause  of  the  dis- 
ease. That  this  is  the  effect  of  strychnia  is,  I  think,  proved  by  cases  narrated  in  my 
former  papers,  but  especially  by  the  case  which  I  mentioned  in  my  last  paper,  a  few  points 
of  which  I  will  recapitulate,  as  it  affords  a  capital  illustration  of  my  meaning  :  A  gentle- 
man, aged  forty,  had  suffered  for  sixteen  years  from  violent  convulsive  epilepsy.  The 
attacks  varied  from  fifty  to  sixty  in  the  month,  and  occurred  chiefly  at  night.  His  mental 
faculties  were  little  if  at  all  impaired,  and  his  general  health  perfectly  good.     No  excit- 


438  PSYCHOLOGICAL   MEDICINE. 

ing  cause  could  be  discovered,  and  he  had  used  every  variety  of  means  without  benefit. 
The  only  fact  which  had  any  bearing  on  the  case  was  that,  previous  to  the  commence- 
ment of  the  attacks,  he  had  been  subject  to  frequent  and  severe  epistaxis,  on  the  stop- 
page of  which  the  attacks  apparently  came  on.  Now,  here  was  a  case  which  would 
undoubtedly  belong  to  that  group  which  Dr.  Reynolds,  in  his  valuable  work  on  epilepsy, 
has  classed  as  most  intractable  and  least  amenable  to  treatment.  Yet  from  the  first  day  of 
this  patient's  commencing  strychnia  the  attacks  diminished,  both  in  number  and  severity, 
in  the  mo-t  remarkable  manner,  so  that  in  the  first  month  of  treatment  the  attacks  were 
only  eleven  in  number  against  fifty-one  in  the  previous  month,  and  this  without  any  in- 
crease of  severity.  Nor  has  this  result  been  merely  a  temporaiy  one ;  but  the  patient, 
who  is  still  under  treatment,  has  gone  on  progressing,  and  I  heard  from  him  only  a  few 
days  since,  to  say  that  he  had  had  an  interval  of  eleven  days  without  any  attack.  I 
single  out  this  case,  as  it  was  one  of  unusual  severity,  was  due  to  no  special  exciting 
cause,  and  belonged  to  a  class  of  cases  which  are  gerierally  admitted  to  be  very  intract- 
able, yet  it  yielded  at  once  to  the  plan  of  treatment  I  mention.  This  might  be  called  a 
case  of  pure  epilepsy,  for  the  disease  was  due  to  no  exciting  cause,  and  this  would  proba- 
bly account  for  the  strychnia  alone  being  sufficient  to  produce  such  favorable  results.  In 
most  cases,  where  various  exciting  causes  are  at  work  keeping  up  the  sensibility  of  the 
medulla  oblongata,  it  is  necessary  to  remove  them  at  the  same  time  that  we  are  restoring 
the  healthy  condition  of  the  nervous  centre  by  strychnia.  The  stomach,  uterus,  pharynx, 
kidney — in  fact,  almost  any  organ — may  be  the  seat  of  these  exciting  causes  ;  and  I  think 
that,  in  the  treatment  of  epilepsy,  the  grouping  of  the  cases  according  to  the  nature  and 
locality  of  their  exciting  causes,  offers  the  best  prospect  of  success.  Thus,  I  would  in 
all  cases  give  strychnia  to  remedy  the  predisposing  cause,  and  at  the  same  time  endeavor 
to  discover  and  treat  the  exciting  cause  or  causes.  In  a  large  class  of  cases,  the  exciting 
causes  of  irritation  will  be  found  to  lie  in  the  gastric  branches  of  the  pneumogastric 
nerve,  and  it  is  in  these  cases  that  nitrate  of  silver,  sulphate  of  zinc  and  copper  are 
so  useful,  and  they  act,  I  believe,  by  deadening  the  sensibility  of  the  nerves  of  that 
part.  In  irritation  proceeding  from  the  uterus  and  sexual  organs  the  bromide  of  potas- 
sium is  very  useful,  coupled  often  with  aloes  and  other  emmenagogues.  In  many  cases, 
where  I  have  found  the  disease  coupled  with  irregular  pulse  and  signs  of  cardiac  de- 
rangement, I  have  found  digitalis  to  act  well.  With  regard  to  diet,  I  find  that  almost  all 
cases  of  epilepsy  bear  a  libei-al  diet,  with  a  fair  amount  of  stimulant,  and  I  have  often 
seen  marked  improvement  follow  a  change  from  a  spare  to  a  full  diet;  of  course,  atten- 
tion must  always  be  paid  to  the  prevention  of  anything  like  a  heavy  meal,  more  espe- 
cially in  those  cases  in  which  gastric  irritation  would  appear  to  be  the  exciting  cause.  I 
have,  since  writing  my  last  paper,  seen  several  cases  of  petit  inal  in  children,  and  in  all 
of  which  I  have  found  strychnia  successful;  and  I  may  here  mention,  that  I  think  some 
distinction  may  be  drawn  between  these  attacks  w^hen  they  occur  prior  to  puberty,  and 
when  they  are  present  in  adults.  I  think  that  in  childhood  they  are  less  destructive  in 
their  effects  upon  the  mind,  and  they  certainly  yield  much  more  readily  to  treatment. 

J.  K.,  eleven,  a  not  unhealthy-looking  boy,  has  been  subject  for  five  years  to  attacks  of 
petit  mat,  with  occasional  severe  fits  of  convulsive  epilepsy,  the  latter  having  usually 
come  on  after  an  excess  in  eating,  though  twice  they  have  occurred  at  night.  He  had 
convulsions  in  infancy.  In  the  slighter  attacks  he  would  lose  himself  for  a  few  mo- 
ments, would  stop  talking,  or  would  talk  incoherently  in  the  middle  of  some  sentence, 
would  occasionally  turn  his  head  over  his  right  shoulder,  and  in  some  cases  his  counte- 
nance would  become  livid.  His  memory  was  not  affected,  and  he  was  very  fond  of 
poetry  and  of  books  generally.  I  commenced  to  treat  him  in  July  last,  enjoining  great 
care  in  diet,  that  it  should  be  liberal,  plain,  but  never  in  great  quantity  at  once.     I  gave 


EPILEPSY.  /  439 

him  Jyth  of  a  grain  of  strychnia  in  solution  twice  daily ;  the  attacks  yielded  almost  at 
once,  and  he  has  now  been  perfectly  well  for  nearly  six  months.  The  attacks  of  petit  vial 
were  here  very  frequent;  sometimes  as  many  as  three  and  four  would  occur  in  one  day. 

The  above  cases  are  merely  selections  from  a  number,  and  are  chosen  as  presenting 
features  very  commonly  met  with — a  plan  which  I  consider  more  likely  to  be  useful  than 
the  narration  of  cases  which  present  symptoms  but  rarely  met  with.  I  may  say  that,  in 
all  the  cases  in  which  I  have  used  strychnia,  I  can  find  but  three  cases  in  which  it  has 
not  produced  any  favorable  result;  and,  on  the  other  hand,  I  have  seen  no  case  in  which 
it  has  produced  an  unfavorable  effect.  With  regard  to  the  doses,  in  severe  cases  I  am 
in  favor  of  giving  a  medium  quantity  for  a  lengthened  period,  rather  than  carrying  the 
dose  very  high  at  first.  Iii  one  case,  narrated  in  a  previous  paper,  the  dose  taken  reached 
as  high  as  ^th  of  a  grain,  twice  daily,  and  this  was  continued  for  some  three  weeks 
without  any  bad  effects  being  perceptible.  But  I  find  that  quite  as  good  results  are  ob- 
tained by  a  long  continuance  of  a  medium  quantity,  say  from  ■^^'^'Cn  to  ^th  of  a  grain, 
the  system  appearing  to  regain  its  nervous  strength  under  the  continued  use  of  the 
medicine. 

On  the  treatment  of  epilepsy  by  belladonna,  Dr.  J.  S.  Ramskill, 
Assistant  Physician  to  the  London  Hospital  and  Physician  to  the 
Hospital  for  Epilepsy  and  Paralysis,  says  : 

Concerning  the  treatment  by,  and  action  of,  belladonna  in  epilepsy,  I  will  give  you,  in 
a  short  compass,  the  results  of  my  experience  in  its  use.  First,  you  must  not  always,  nor 
even  usually,  look  for  immediate  and  palpable  beneficial  results.  The  number  of  fits  at 
first  may  not  lessen  in  equal  times ;  very  frequently,  the  reverse  obtains  ;  and  you  may  ex- 
pect, for  three  or  four  weeks  after  commencing  it,  even  in  the  most  appropriate  cases,  a 
complaint  that  the  patient  gets  worse ;  but  after  six  -or  eight  weeks,  if  any  amelioration 
occur,  it  will  be  decided  and  progressive.  At  first  the  dose  should  be  very  small,  and 
gradually  augmented  until  the  pupil  shows  signs  of  its  action,  and  the  patient  complains 
of  both  alteration  in  sight  and  dryness  of  throat.  Having  obtained  this  result,  and 
maintained  it  for  some  weeks,  the  dose  may  be  gradually  diminished ;  but  its  effects  on 
eye  and  throat  are  not  to  be  so  diminished  as  to  become  imperceptible  to  the  patient,  but 
only  so  far  lessened  as  to  cease  causing  absolute  discomfort.  The  other  toxic  effects  of 
belladonna  are  wholly  uncalled  for.  Patients  vary  greatly,  both  as  to  susceptibility  in  the 
action  of  the  drug,  and  in  other  respects.  The  annoyance  as  to  dry  throat  and  disturbed 
vision,  which,  at  the  expiration  of  a  month,  may  be  said  to  be  unendurable,  will  now  and 
then  cease,  the  dose  being  the  same,  or  even  slightly  increased ;  but  I  may  remai'k,  these 
cases  always  improve  most  rapidly.  I  prefer  to  give  the  drug  in  an  eighth  of  a  grain 
dose  three  times,  or  only  twice,  daily,  for  a  week ;  then  a  quarter  of  a  grain  for  four- 
teen days;  a  third  for  the  next  fourteen  days,  at  which  time  its  physiological  action 
will  in  most  cases  be  manifest.  I  think  it  wise  to  halt  at  this  dose  for  two  or  three 
months,  slightly  increasing  the  dose  if  the  patient  shows  diminished  susceptibility  to 
its  influence,  decreasing  it  if  the  reverse  happens,  and  then  gradually  dropping  it  to  the 
quantity  first  administered.  I  have  given  as  much  as  four  grains  for  a  dose,  but  very 
rarely.  I  think  it  imperative  to  say,  that  I  have  never  been  able  to  give  in  epilepsy  the 
large  doses  which  Dr.  Fuller  has  succeeded  in  administering  in  other  diseases  of  a  con- 
vulsive character.  In  this  remark  I  am  supported  by  the  authority  of  my  colleague,  Dr. 
Brown-Sequard,  who  has  arrived  at  the  same  conclusion.  One  objection  to  the  use  of 
belladonna,  when  you  cannot  see  your  patient  at  regular  intervals,  arises  from  its  uncer- 


440  PSYCHOLOGICAL    MEDICINE. 

tainty  of  strength  and  corresponding  difference  of  action.  To  those  who  wish  to  use  a 
preparation  of  uniform  strength,  having  similar,  and,  in  some  cases,  improved  properties 
of  belladonna,  the  salts  of  atropia  are  now  easily  procurable.  The  best  of  these  is  the 
valerianate  of  atropia;  the  commencing  dose  a  hundred-and-twentieth  of  a  grain.  Hith- 
erto, I  have  preferred  belladonna,  having  had  a  strong  desire  to  find 'what  it  could,  and 
if  possible,  what  it  could  not  accomplish  in  the  treatment  of  epilepsy.  It  is  right  to  say 
there  are  different  methods  of  administering  belladonna.  Trousseau  gives  a  centigramme 
of  the  extract  and  an  equal  quantity  of  the  powder  of  belladonna  for  the  first  month,  in 
the  evening  of  each  day.  He  gives  it  at  this  time  because  of  the  frequent  nocturnal 
character  of  epilepsy,  and  partly  because  of  the  disagreeable  effect  on  the  sight  and  throat 
during  its  early  administration.  During  the  second  month  he  gives  two  such  pills  at  the 
same  time,  and  during  the  third  month  three  pills.  If,  at  the  end  of  six  or  nine  months, 
the  frequency  of  the  fits  is  decreased,  he  increases  the  dose.  He  asserts  that,  of  120 
patients,  he  has  cured  twenty.  A  most  important  question  now  arises, — Do  we  know 
anything  of  the  nature  of  the  action  of  belladonna  beyond  the  empirical  results  obtained 
in  treatment  ?  If  a  drop  of  solution  of  belladonna  or  atropine  be  dropped  on  the  foot 
of  a  frog  properly  prepared,  and  fixed  on  the  field  of  a  microscope,  the  bloodvessels  will 
be  seen  to  contract,  and  they  will  remain  in  this  condition  for  a  considerable  time.  For 
comparing  the  action  of  opium,  a  solution  of  the  latter,  similarly  prepared,  was  applied 
to  another  part,  and  the  vessels  were  immediately  dilated.  Now,  belladonna,  internally 
administered  in  medicinal  doses,  causes,  first,  dilatation  of  the  pupil,  with  dimness  of 
vision;  secondly,  dryness  of  throat  and  difficulty  of  swallowing;  thirdly,  increased  tone 
of  involuntary  muscle ;  fourthly,  it  relaxes  the  bowels,  and  cures  incontinence  of  urine, 
arising  from  weak  sphincter  vesica.  As  dilatation  of  pupil  is  one  of  the  earliest  phe- 
nomena, let  us  see  if  we  can  account  for  it.  There  are  two  sets  of  fibres  in  the  iris.  It 
is  well  known  that  the  sympathetic  is  the  motor  nerve  of  the  external  longitudinal  fibres 
of  the  iris,  which  radiate  from  the  centre  to  the  circumference.  The  branch  of  nerves 
supplying  these  fibres  comes  from  the  cervical  ganglia  of  the  sympathetic.  Excitation 
of  this  nerve,  from  any  cause,  will  cause  a  contraction  of  these  longitudinal  fibres,  and  a 
corresponding  dilatation  of  pupil.  There  is  also  a  circular  set  of  fibres  immediately  sur- 
rounding the  margin  of  the  pupil.  This  set  is  under  cerebral  control ;  that  is  to  say,  its 
motor  supply  comes  from  a  branch  of  the  third  nerve.  Any  irritation  in  the  brain  or 
along  the  trunk  of  the  nerve,  or  an  excitation  by  light  on  the  retina  acting  in  a  reflex 
manner,  will  stimulate  this  branch  of  the  third  to  action,  and  cause  contraction  of  pupil. 
But  we  may  have  dilatation  of  pupil  without  increased  action  of  the  sympathetic ;  it 
may  be  acting  normally,  then  the  third  nerve  must  be  supposed  deficient  in  power.  This 
is  a  common  result  observed  in  compression  of  brain.  On  the  other  hand,  contraction  of 
pupil  may  be  present  without  abnormal  activity  of  the  third  being  necessarily  supposed. 
This  condition  is  invariably  produced  by  section  of  the  sympathetic  in  the  neck.  Dila- 
tation of  pupil  may,  in  short,  depend  upon  the  action  of  the  sympathetic  being  in  excess, 
or  in  diminished  power  of  the  cerebral  nerve.  In  epilepsy  it  is  easy  to  observe,  from 
collateral  symptoms  and  the  general  condition  of  the  patient,  that  dilated  pupil,  when  it 
exists,  which  is  much  rarer  than  a  normal  condition,  is  usually  caused  by  an  active  sym- 
pathetic overpowering  the  third  nerve.  The  same  dilatation  may  be  observed  in  most 
convalescents  after  acute  disease,  and  in  most  affections  involving  extreme  debility ;  but 
here  it  would  be  more  correct  to  say  that  the  dilatation  was  rather  the  effect  of  a  com- 
pressed condition  of  the  third  cerebral  nerve  accompanying  a  normal  sympathetic  than 
of  an  active  sympathetic  accompanying  a  normal  condition  of  the  cerebral  nerve.  I  have 
said  the  branches  of  the  sympathetic  nerve  which  go  to  the  iris  come  from  the  cervical 
sympathetic.     Dr.  A.  Waller,  with  Professor  Budge,  have  made  experiments  which  seem 


EPILEPSY,  441 

to  prove  that  the  nerve-fibres  of  the  cervical  sympathetic,  which  go  to  the  iris,  originate 
from  the  spinal  cord,  between  the  sixth  cervical  and  the  fourth  dorsal  vertebrje.  Dr. 
Brown-Sequard  has  ascertained  that  the  origin  of  the  fibres  of  the  sympathetic  going  to 
the  iris  are  still  more  extended.  I  have  mentioned  that  division  of  the  cervical  sympa- 
thetic allows  the  ilncontrolled  third  cerebral  nerve  to  contract  the  iris.  Dr.  Brown- 
Sequard  has  shown  that  a  section  of  the  spinal  cord,  as  high  as  the  level  of  the  fifth  cer- 
vical or  as  low  as  the  ninth  or  tenth  dorsal  vertebrse,  affects  the  iris  in  the  same  manner 
but  in  a  less  degree  than  section  of  the  sympathetic.  On  the  other  hand,  Schiff  has 
shown  that  some  of  the  fibres  animating  the  iris  ascend  the  cervical  part  of  the  spinal 
cord,  and  most  probably  go  up  to  the  medulla.  I  may  also  say  here  that  the  sympathetic 
is  the  motor  nerve  of  the  bloodvessels,  supplying  various  parts  of  the  head.  It  is  espe- 
cially interesting  to  know  the  origin  of  these  vaso-motor  nerves,  especially  in  relation  to 
loss  of  consciousness,  the  initial  movement  of  a  fit  of  epilepsy,  and  also  in  regard  to  the 
pathology  of  the/f/'?V  nial,  as  well  as  the  great  light  such  knowledge  would  throw  on  the 
action  of  belladonna  in  epilepsy.  Dr.  Brown-Sequard  discovered,  some  years  ago,  that 
the  motor  nerves  of  the  bloodvessels  going  to  various  parts  of  the  head  come  out 
chiefly  from  the  spinal  cord  by  the  roots  of  the  last  cervical  and  first  and  second  dorsal 
nerves.  He  thinks,  however,  their  real  place  of  origin  to  be  partly  the  spinal  cord,  partly 
the  higher  portions  of  the  encephalon,  but  chiefly  the  medulla  oblongata  and  the  neigh- 
boring parts  of  the  encephalon.  In  the  case  of  R.  P.,  it  will  be  remembered  the  ferrum 
candens  was  applied  to  each  side  of  the  spine,  opposite  the  last  cervical  and  first  dorsal 
vertebrae.  The  reason  will  now  be  apparent.  The  vaso-motor  nerve  fibres  are  able  to 
contract  the  bloodvessels  directly,  when  excited.  We  hope,  by  frequently  cauterizing 
the  tissues  opposite  the  seat  of  exit  of  these  nerves  from  the  spine,  to  effect  some  change 
in  the  nutrition  of  the  parts  to  which  these  nerves  are  distributed.  We  can  now  under- 
stand the  nature  of  the  action  of  belladonna  in  producing  dilatation  of  the  pupil,  and, 
from  its  effect  on  the  iris,  we  can  deduce  a  strong  probability  of  the  nature  of  its  action 
in  epilepsy.  It  is  a  stimulant  to  the  sympathetic,  the  motor  nerve  of  the  bloodvessels, 
and  it  is  only  on  this  supposition  we  can  account  for  the  other  physiological  effects  of  the 
drug. 

I  would  add,  although  experience  shows  belladonna  is  one  of  the  most  powerful  con- 
tractors of  the  bloodvessels  of  the  spinal  cord  and  its  membranes,  it  has  a  comparatively 
feeble  action  on  those  of  the  brain.  I  speak  of  its  administration  in  medicine,  not  in 
poisonous  or  fatal  doses.  Hence  arises  its  extraordinary  adaptability  in  epilepsy,  where 
we  have  dilatations  of  vessels  or  turgescence  in  the  medulla  and  its  neighborhood ;  of  its 
still  more  marked  efficacy  in  inflammation  and  congestion  of  the  spinal  cord  and  its 
membranes,  as  well  as  of  its  comparative  inutility  (administered  alone)  in  those  cases  of 
morbid  activity  of  brain,  connected,  as  we  think,  with  more  or  less  congestion  of  gray 
matter,  in  some  forms  of  incipient  insanity,  associated  with  sleeplessness  and  suicidal 
tendency,  as  well  as  in  some  other  cerebral  diseases. 


442  PSYCHOLOGICAL   MEDICINE. 

CHAPTER  XXII. 

HYSTERO-EPILEPSY. 

It  has  been  claimed  by  some  neurologists  that  the  term  hystero- 
epilepsy  was  a  misnomer,  that  the  disease  in  question  was  really  hys- 
teria major,  as  differing  from  the  hysteria  minor  of  every  day  prac- 
tice. Prof.  Charcot  himself,  we  think,  takes  this  view,  that  what  at 
first  glance  is  evidently  epileptic  is  epileptic  only  in  outer  form.  The 
case  which  forms  the  text  for  this  chapter  has  proved  to  me,  how- 
ever, that  there  is  epilepsy  present  in  certain  grave  cases  of  hystero- 
epilepsy,  and  that  there  is  also  organic  lesion  of  the  brain  connected 
with  it,  sclerosis,  as  in  old  cases  of  uncomplicated  epilepsy.  My 
case  had  been  apparently  cured  by  central  galvanization,  followed  by 
general  faradization,  nerve  tonics,  full  feeding  and  rest ;  the  convul- 
sions had  ceased,  although  the  patient  did  not  remain  under  treat- 
ment as  long  as  we  desired,  when  after  a  lapse  of  some  months  the 
disease  reappeared,  and  the  patient  finally  died  at  home.  The  lesions 
found  on  autopsy  were  those  which  I  correctly  predicted  would 
have  been  found  if  the  case  had  gone  on  to  a  fatal  termination  in- 
stead of  making,  as  I  trusted  she  had,  a  recovery  while  in  New 
York. 

The  history  of  this  very  interesting  case  is  as  follows : 
During  the  latter  part  of  April,  1880,  I  was  called  in  consultation 
by  my  friend  Dr.  J.  Marion  Sims,  to  see  a  case  of  hystero-epilepsy.  I 
found  a  lady  of  twenty  years  of  age,  who  was  suffering  from  cerebral 
and  spinal  anaemia ;  who  was  having  terrific  convulsions  day  and 
night,  which  were  aggravated,  both  in  duration  and  intensity,  by 
anything  that  disturbed  her  very  excitable  nervous  system.  Her 
history,  as  given  by  the  mother,  was  as  follows  :  During  childhood 
she  had  very  severe  convulsions  with  every  infantile  disease,  and  also 
whenever  she  was  in  an  anaemic  condition.  This  points  decidedly  to 
epilepsy.  These  convulsions  from  infancy,  presented  an  epilepti- 
form type.  When  she  was  ten  and  a  half  years  old  menstruation 
appeared;  and  at  the  menstrual  periods  thereafter,  until  she  was  four- 
teen years  old,  the  convulsions  were  of  the  severest  type,  exhausting 
her  very  much.  Another  unfavorable  symptom,  for  periodical  neu- 
roses are  notably  intractable  to  treatment.  She  was  treated  by 
nearly  all  the  physicians  of  eminence,  both  at  home  and  abroad,  but 
with  very  little  success.     While  abroad,  occupied  with  sight-seeing 


HYSTERO-EPILEPSY.  443 

and  taking  a  great  deal  of  exercise  in  Switzerland,  she  had  almost 
absolute  freedom  from  the  convulsions,  although  she  was  very  thin. 
This  is  still  another  fact  confirmatory  of  the  existence  of  true  epi- 
lepsy, as  my  experience  has  taught  me  in  treating  epilepsy  that  my 
patients  who  took  long  walks  out  of  doors,  suffered  the  least  from  the 
epileptic  seizures. 

Sir  Thomas  Watson  gave  it  as  his  opinion  that  the  convulsions 
would  disappear  of  themselves  as  she  grew  older,  and  gave  the  diag- 
nosis of  hystero-epilepsy.  He  suggested  no  treatment.  The  mother 
and  daughter  returned  home,  and  on  their  arrival  in  America  the  con- 
vulsions reappeared  with  renewed  intensity.  The  patient  would 
sometimes  have  forty  convulsions  in  the  twenty-four  hours.  The 
mother  applied  to  Dr.  W.  A.  Hammond,  and  he  sent  her  to  Dr.  Sims 
for  his  opinion  relative  to  the  propriety  of  performing  Battey's  opera- 
tion of  oophorectomy,  hoping  that  this  would  give  relief  There  was 
a  distinct  epileptic  aura  at  this  time,  starting  from  the  uterus  and  ra- 
diating towards  each  ovary,  where  it  sometimes  stopped,  but,  if  it 
reached  the  epigastrium  it  always  resulted  in  a  terrific  convulsion. 
Pressure  on  the  uterus  and  ovaries  by  conjoined  manipulation  caused 
the  sensation  of  the  aura,  but  failed  to  produce  or  check  actual  con- 
vulsions. She  never,  I  think,  absolutely  lost  consciousness  during 
the  seizures.  As  no  treatment  had  heretofore  given  any  relief,  Bat- 
tey's operation  was  determined  upon  and  was  performed  by  Dr.  Sims, 
January  nth,  1880.  The  ovaries  were  found  to  be  diseased,  having 
undergone  cystic  degeneration.  The  patient  soon  recovered  from 
the  effects  of  the  operation,  but  her  convulsions  were  not  controlled 
by  it.  I  think,  however,  that  by  this  operation  Dr.  Sims  laid  the 
corner-stone  of  the  improvement  which  I  afterwards  obtained,  as  I 
do  not  believe  that  with  diseased  ovaries  I  could  have  been  as  suc- 
cessful as  I  was. 

It  was  decided  that  the  patient  should  be  placed  under  my  care, 
and  I  accordingly  took  charge  of  her  May  2 2d,  1880,  at  my  private 
hospital  for  nervous  diseases.  At  this  time  she  had,  as  I  have  said, 
terrific  convulsions  night  and  day,  the  element  of  epilepsy  predomina- 
ting. There  was  no  epileptic  cry,  properly  speaking,  but  she  would 
call  out  "  Mamma!"  and  become  very  pale  ;  there  would  be  a  twist- 
ing and  squinting  of  the  eyes  and  terrible  convulsive  movements  of 
the  legs  and  arms,  strongly  impressing  one  with  their  close  alliance 
with  the  most  aggravated  movements  in  the  worst  cases  of  chorea.  She 
would  come  out  of  a  severe  convulsion  instantly,  with  panting  breath, 
as  if  she  had  just  come  in  from  an  excessively  long  walk.     In  a  few 


444  PSYCHOLOGICAL    MEDICINE. 

seconds  she  would  feel  comfortable  again.  The  thumbs  were  not 
folded  into  the  palms  of  the  hands.  It  was  decidedly  the  most  unique 
exhibition  I  have  ever  witnessed  in  the  whole  course  of  my  practice. 
She  differed  entirely  from  most  patients  with  hysteria,  in  that  she  suf- 
fered mentally  very  much,  fearing  in  her  own  mind  that  she  had  true 
epilepsy,  and  at  times  would  grow  quite  morbid  about  it.  At  such  times 
I  tried  to  raise  her  spirits  by  telling  her  that  she  would  certainly  recover 
in  time,  and  she  then  would  become  more  cheerful  and  make  every  ef- 
fort to  fight  off  the  convulsions.  I  questioned  the  mother  closely 
about  hereditary  predisposition,  but  she  denied  any  hereditary  taint  of 
nervous  disease,  or  anything  else  that  could  even  remotely  have  influ- 
enced the  child  unfavorably.  I  questioned  her,  also,  very  closely  about 
her  own  mental  condition  while  pregnant,  as  it  is  my  firm  belief  that 
the  future  life  of  an  unborn  babe  is  strongly  affected  by  the  mental 
state  of  the  mother  during  gestation ;  but  she  could  recollect  no  dis- 
turbing circumstances,  even  of  a  trivial  character.  The  mother  was  a 
woman  of  more  than  ordinary  mind  and  of  a  remarkably  equable  dis- 
position. I  came,  therefore,  to  the  conclusion  that  the  pathology  of 
the  case  I  had  to  deal  with,  was  that  of  an  unstable  nerve  element ; 
and  that  the  seat  of  the  disease  was  in  the  nerve  centres,  with,  very 
probably,  the  principal  irritation  in  the  cortical  motor  zone  of  the  central 
nervous  region.  There  was  marked  anaemia  of  the  nervous  centres. 
Upon  what  pathological  process  in  the  brain  the  convulsions  in  her 
infancy  depended,  it  is  hard  to  tell,  although  I  presume  it  would  be 
fair  to  consider  it  a  lesion  of  irritation  of  the  cortical  motor  zone  of 
the  cerebrum  from  innutrition,  depending  upon  anaemia  of  the  brain 
and  cord. 

When  she  was  about  ten  years  old  there  was  gastric  disturbance, 
and  for  three  years  she  ate  scarcely  anything  at  all.  Primarily,  I  had 
nerve  cells  to  feed  in  order  to  restore  the  integrity  of  the  nervous 
system,  and  I  accordingly  fed  her  with  milk  very  plentifully,  and 
gave  her  phosphorus  and  the  animal  fats  in  abundance.  I  made  her 
rest  nearly  all  the  time  at  first,  until  her  muscular  strength  returned, 
when  I  had  her  take  a  very  moderate  amount  of  exercise  daily.  I 
gave  her,  to  quiet  the  neuralgic  pelvic  regions,  which  distressed  her 
very  much,  hypodermic  injections  of  atropia  -g-V  grain  each,  with 
almost  instantaneous  relief  every  time.  I  administered  the  galvanic 
current  daily  for  half  an  hour  in  the  form  of  central  galvanization, 
the  negative  pole  being  placed  on  the  pit  of  the  stomach,  and  the 
positive  over  the  top  of  the  head,  the  cervical  sympathetic,  and  on 
each  side  of  the  seventh  cervical  vertebra,  using  a  moderately  strong 


HYSTERO-EPILEPSY.  445 

current  which  could  not  be  disagreeable  to  the  patient.  I  considered 
this  indicated  to  improve  the  nutrition  of  the  deeper  tissues  of  the 
nervous  system,  and  to  combat  the  spinal  anaemia  and  irritation  which 
existed.  I  also  gave  her  iron  and  nux  vomica.  As  she  slept  very 
badly,  waking  perhaps  twenty  times  in  the  night  with  convulsions,  I 
gave  her  a  night  mixture  of  sodium  bromide,  60  grains,  and  tincture 
of  cannabis  indica,  30  minims,  with  a  warm  bath  three  times  a  week 
at  night.  I  soon  began  to  see  a  marked  improvement.  The  com- 
bination of  sodium  and  cannabis  indica  enabled  the  patient  to  sleep, 
whereas,  previously  she  had  lain  awake  nervously  waiting  for  the 
return  of  the  next  convulsion.  Making  her  sleep  without  disturbing 
her  digestion  was  a  great  point  gained.  Duquesnel's  aconitia  was 
given  once  a  day  in  doses  of  y|-g-  of  a  grain,  and  after  about  two  weeks 
of  its  administration  I  gave  hypodermic  injections  of  Fowler's  solution 
until  the  physiological  effects  of  arsenic  appeared*  when  I  stopped  it.  I 
diluted  the  Fowler's  solution  one-half  with  water  to  prevent  the  forma- 
tion of  abscess,  commencing  with  3  minims  and  running  up  to  20 
minims  (or  40  in  all  including  the  water).  I  did  this  because  the 
nature  of  the  convulsions  suggested  chorea,  and  I  determined  to 
combat  any  such  influence  in  the  central  nervous  system. 

It  miust  be  remembered  that  almost  from  infancy  my  patient  had 
been  taking  some  drug  or  other,  until  she  had  taken  almost  every- 
thing. She  had  never  taken  aconitia,  atropia,  arsenic,  or  the  sodium 
and  cannabis  indica  mixture  before  ;  neither  had  she  ever  had  elec- 
tricity properly  applied.  I  had  also  to  treat  an  inflammation  of  the 
cervix  uteri,  which  I  did  by  making  a  cup  of  absorbent  cotton  wrung 
out  of  warm  water  and  filled  with  glycerole  of  bismuth,  which,  for 
three  weeks,  I  applied  every  day,  at  last  completely  curing  that  source 
of  irritation  to  the  nervous  system.  The  patient  began  to  gain  in 
health  and  appearance,  and  evinced  a  desire  to  eat  heartily  and  take 
exercise,  and  a  flush  of  healthy  color  began  to  show  in  her  lips  and 
cheeks.  The  convulsions  steadily  diminished  in  frequency  and  also 
in  intensity.  I  now  substituted  general  faradization  for  central  gal- 
vanization, and  the  improvement  still  continued.  In  this  connection 
I  would  say  that  I  am  sure,  from  the  results  of  several  cases  of  epi- 
lepsy that  I  have  treated  by  the  induced  current  and  strychnia,  that 
the  induced  or  faradic  current  possesses  a  special  power  for  good 
over  the  nervous  system  in  such  cases.  The  convulsions  at  the  end 
of  two  months  had  completely  left  her  during  the  daytime.  I  had 
now  dropped  the  arsenic  and  aconitia,  still  adhering  to  electricity, 
the  sodium  bromide  and  cannabis  indica  at  night,  and  the  warm 


446  PSYCHOLOGICAL   MEDICINE. 

baths,  together  with  phosphorus  and  cod-liver  oil  after  each  meal. 
She  was  now  having  perhaps  seven  or  eight  seizures  at  night,  but 
slept  soundly  between  them.  These  grew  less  in  frequency  and  in- 
tensity, and  at  the  expiration  of  three  months  I  sent  her  home  to  the 
West  altogether  a  very  different  looking  girl  from  what  she  was  in 
May.  She  had  gained  some  twenty  pounds  of  flesh,  and  felt  very 
well.  There  was  still  remaining  some  convulsive  twitching  of  the 
muscles  at  night,  but  nothing  like  a  true  convulsion  as  before.  The 
patient  was  obliged,  for  family  reasons,  to  return  to  the  West  at  the 
beginning  of  September,  although  she  ought  to  have  remained  under 
treatment  until  at  least  six  months  had  elapsed;  and  had  she  done  so, 
the  gratifying  results  which  I  had  obtained  might  have  been  made  per- 
manent. The  cod-liver  oil,  which  she  took  in  teaspoonful  doses,  was 
of  immense  benefit  to  her,  as  it  always  is,  in  my  experience,  in  the 
class  of  hereditary  diseases  to  which  epilepsy  belongs,  as  it  seems  to 
exert  a  special  prophylactic  effect. 

Respecting  the  cerebral  localization  in  this  case,  my  opinion  was 
expressed  as  follows  before  the  patient  left  for  home,  and  the  subse- 
quent events  confirmed  the  correctness  of  my  opinion  : 

That  the  upper  and  lower  limbs,  the  forearm,  the  hand,  and  the 
facial  muscles  were  all  affected  by  the  convulsions.  There  was  an 
alteration  in  speech — a  deficiency  of  impulse  and  some  difficulty  in 
the  conduction  of  speech — at  times ;  in  other  words,  partial  and  in- 
complete verbal  paralysis.  The  brain  disease  evidently  affected  the 
ascending  parietal  convolutions,  which  are  the  cortical  centres  for 
motility — in  the  innermost  and  superior  part  for  both  upper  and  lower 
limbs ;  in  the  middle,  for  the  forearm  and  head;  and  in  the  external 
or  inferior  part,  for  the  facial  muscles.  The  most  inferior  part  of  the 
ascending  frontal  convolution  and  the  foot  of  the  third  frontal  con- 
volution, which  are  the  motor  centres  for  the  muscles  which  affect 
the  pronunciation  of  words,  I  considered  also  as  undoubtedly  affected, 
leading  to  the  alteration  and  deficiency  of  impulse  of  speech.  I  also 
considered  it  probable  that  there  was  bilateral  circulatory  disorder 
of  the  cornu  ammonis,  which,  I  said,  if  the  case  had  progressed  for 
the  worse,  would  undoubtedly  have  proceeded  to  atrophy  and  scle- 
rosis. The  cornu  ammonis  has  this  relation,  histologically,  to  the 
motor  functions,  that  its  cellular  elements  consist  of  a  cortical  stra- 
tum of  grand  pyramidal  nerve-cells,  analogous  to  the  structure  of 
all  the  central  motor  nervous  regions. 

Charcot,  in  his  Lectures  on  the  Diseases  of  the  Nej'vons  System, 
speaks  of  a    case  of  hystero-epilepsy,   where   he   found    bilateral 


HYSTERO-EPILEPSY.  44/ 

sclerosis  of  the  cornu  ammonis ;  and  in  autopsies  in  cases  of  epi- 
lepsy, Foville,  Bouchet,  Mynert,  and  Pfleger  all  unite  in  describing 
this  lesion  of  sclerosis  and  atrophy  of  the  cornu  as  of  frequent  oc- 
currence. On  the  other  hand,  the  physiological  results  in  Kussmaul 
and  Tenner's  experiments  on  epilepsy  in  animals,  where  epileptic 
convulsions  were  artificially  induced,  seemed  to  show  that  ablation 
of  the  cornu  ammonis  had  no  effect  on  the  general  convulsions.  We, 
as  physicians,  however,  are  more  concerned  with  clinical  and  patho- 
logical than  with  physiological  results,  however  important  the  latter 
may  be.  The  pathology  of  this  interesting  case  of  hystero-epilepsy 
I  therefore  considered,  when  the  patient  left  me,  to  have  been  a  circu- 
latory disorder,  accompanied  by  great  irritation  of  the  cortical  motor 
zone  of  the  central  nervous  regions,  which,  if  the  case  had  progressed 
unfavorably — as  after  a  lapse  of  some  months  it  did — would  have  led  to 
atrophy  and  sclerosis  of  the  ascending  parietal  convolutions,  the  most 
inferior  part  of  the  ascending  frontal  convolution,  and  the  foot  of  the 
third  frontal  convolution,  and  of  the  cornu  ammonis.  This  was  what 
I  put  on  record  concerning  this  case  when  she  went  away.  The  ac- 
companying letters  from  her  mother,  and  one  from  the  physician  who 
at  last  made  the  autopsy,  show  the  redevelopment  of  convulsions, 
the  lesion  of  irritation  ending  in  atrophy  and  sclerosis  of  the  cortical 

motor  zone : 

"January  25TH,  1882. 
"  Dr.  Mann: 

"  My  dear  Friend. — Your  kind  letter  reached  me  some  time  since  and  would  have 
been  answered  immediately  could  I  have  obtained  the  information  you  desired.  Yester- 
day I  received  a  letter  from  Dr.  Gapen,  with  many  apologies  for  the  delay,  and  the  wrif- 

te7i  examination,  of  which  I  send  you  a  copy.     He  has  never  attended ,  and  all 

he  knows  of  her  he  has  gathered  from  other  physicians  and  my  family  when  I  was  absent. 

I  had  indeed  hoped  that would  grow  out  of  her  troubles  ;  and  as  her  general 

health  seemed  at  times  to  be  almost  perfect,  I  felt  I  had  good  reason  to  hope.  Her  brain 
grew  more  and  more  active,*  and  she  was  greatly  changed.  She  read  a  great  deal ;  was 
always  busy  and  hopeful,  most  of  the  time  very  cheerful.  She  grew  very  appreciative  of 
what  was  done  for  her,  and  up  to  the  last  spared  me  all  shq  pould  from  sharing  her  bad 
feelings.  For  more  than  a  week  before  she  died  I  was  aware  that  there  was  a  change  in 
her  symptoms,  and  hardly  knew  what  to  look  forward  to ;  but,  basing  my  hopes  upon 
the  many  things  that  had  been  told  me,  I  looked  upon  any  change  as  favorable.  Last 
winter  she  was  as  bad,  seemingly,  as  she  was  this  time,  with  this  exception,  there  was  no 
visible  sign  of  congestion  of  the  brain,  as  at  this  time.  Then,  when  I  felt  she  was  surely 
dying,  she  dropped  into  a  sleep  which  lasted  two  nights  and  one  day  without  awakening, 
—for  three  days  she  did  not  speak, — then  she  got  up  and  dressed  herself,  and  sat  down 
in  a  little  chair  by  the  window,  and,  looking  up  at  me,  she  said  :  '  Mamma,  I  never  looked 
at  you  before  with  the  thought  of  how  you  looked.  Everything  seems  so  different  to  me 
from  what  it  ever  did — my  room — all  my  friends — everything.'     She  had  not  been  able 

*  Her  mind,  up  to  the  time  she  came  to  New  York,  had  been  that  of  a  child, — unde- 
veloped. 


448  PSYCHOLOGICAL   MEDICINE. 

to  lie  do\Yn  without  feeling  badly.  Now  she  could  lie  or  sit,  and  it  all  seemed  so 
lovely  to  her.  She  went  on  improving  in  strength,  and  with  everything  so  natural  that 
we  both  felt  paid  for  all  we  had  done'  and  all  we  had  suffered.  This  state  of  things  lasted 
for  two  months,  and  then  came  a  return  of  the  old  symptoms.  The  spasms  increased 
from  one  a  week  to  one  a  day,  and  then  three,  and  so  on,  to  sixteen  or  twenty  duriiig  the 
twenty-four  hours.  Sometimes  she  would  go  for  a  week  without  any  exhibition  of  nerv- 
ousness, etc. 

"  As  ever  yours, ." 

After  death,  the  following  appearances  were  found  by  the  very  able 
and  intelligent  physician  who  made  the  autopsy,  and  who  kindly 
forwarded  the  results  to  me  : 

"  Post-moriefn   Exami7iation  of  the   Body  of  Miss  Twenty  four   hours    after 

Death. — Found  atrophy  of  the  uterus,  with  absence  of  the  ovaries.  Wounds  made  in 
the  removal  of  the  latter  perfectly  cicatrized.  Evidences  of  severe  general  peritonitis, 
in  adhesions  of  the  intestines,  both  to  the  abdominal  walls  and  to  each  other.  Nothing 
abnormal  in  stomach  or  intestinal  lining.  Lungs  and  heart  also  normal.  On  opening 
the  calvarium,  the  brain  was  found  gorged  with  venous  blood.  Every  vein  and  sinus 
was  distended  to  its  fullest  capacity.  There  was  no  effusion  of  blood  either  on  the  sur- 
face or  into  the  tissue  of  the  brain.  The  dura  mater  y^zs,  glued  down  to  the  pia  mater 
over  a  large  space,  covering  nearly  the  whole  of  the  top  of  the  brain,  by  a  thick  and  strong 
effusion  of  lymph.  These  adhesions  were  very  firm,  especially  along  the  borders  of  the 
longitudinal  fissures.  On  the  left  side  nothing  further  than  this  was  found  abnormal,  but 
on  exposing  the  7-ight  hemisphere,  the  eye  was  at  once  attracted  by  a  very  marked  depres- 
sion, extending  over  an  irregular  area  of  nearly  two  inches  in  diameter,  and  involving 
the  second  frontal,  ascendiiig frontal,  and  ascending  parietal  convolutions.  This  area  was 
apparently  depressed  about  J^  inch  below  the  surface ;  was  flat,  the  interspaces  between 
the  convolutions  being  filled  with  lymph,  and  the  pia  mater  translucent  over  the  depres- 
sion from  the  effusion  of  lymph  into  it.  To  the  touch  this  part  was  very  much  firmer 
and  denser  than  the  rest  of  the  brain.  The  borders  of  the  hardened  area  were  sharply 
defined  to  the  touch.  This  indurated  condition  extended  through  the  entire  thickness 
of  the  gray  matter  and  into  the  white  matter  below,  being  in  all  about  half  an  inch  in 
depth  and  continuing  the  same  in  extent  and  in  the  sharp  definition  of  its  borders.  On 
laying  back  a  layer  of  the  brain  deep  enough  to  include  the  entire  induration  and  in- 
cludino-  it  between  the  fingers,  the  sclerosed  part  was  so  much  harder  than  the  surround 
ing  parts  as  to  seem  like  a  foreign  body.  In  the  absence  of  microscopic  investigation, 
which  is  yet  unfinished,  I  can  only  add  that  the  lesion  seemed  a  sclerosis,  which  -was 
probably  the  result  of  chronic  inflammatory  action.  The  lesion  furthermore  belonged  to 
the  irritative  as  opposed  to  the  destrtictive  class,  as  there  is  no  evidence  of  any  marked 
loss  of  function  of  this  part  of  the  brain.  If,  as  I  anticipate,  the  lesion  proves  to  be  irri- 
tative wholly  in  its  character,  it  will  be  the  most  extensive  and  important  of  its  class 
ever  reported.  When  the  microscopic  work  is  finished,  I  will  take  pleasure  in  adding 
to  this  report  such  additional  facts  as  may  be  thereby  brought  to  light. 

"  Yours  very  respectfully,  Clark  Gapen." 

In  hystero-epilepsy  the  influence  of  nitrate  of  amyl  in  mitigating 
or  temporarily  postponing  convulsions  is  incontestable,  even  although 
the  progress  of  the  disease  may  not  be  interfered  with.  Applications 
of  ice,  and  especially  pressure,  should  be  made  in  the  region  of  the 
ovaries,  where  we  find  almost  invariably  hyperaesthesia  with  semi- 


CHOREA. 


449 


anaesthesia  on  the  opposite  side.  These  appliances,  if  resorted  to 
contemporaneously  with  the  aura,  prevent  the  fit,  and  if  during  the 
attack,  they  arrest  it  oftentimes.  The  close  of  the  various  steps  and 
stages  of  hystero-epilepsy  terminating  in  recovery  may  sometimes 
be  very  abrupt,  even  when  the  disease  has  lasted  for  years.  These 
cases  generally,  although  not  always,  occur  in  sensitive,  self-willed, 
and  parentally  indulged  girls,  who  have  been  subject,  in  early  life,  to 
convulsions.  They  prefer  to  any  duties,  solitude,  secret  reading,  and 
reverie,  taking  little  food  and  less  sleep.  We  may  have  fever,  inco- 
herence, convulsive  crisis,  somnambulism,  and  catalepsy  and  choreic 
movements,  all  making  their  appearance  in  this  disease.  Perfect 
recovery  will  follow  wise  treatment  in  the  cases  in  which  the  element 
of  hysteria  predominates  over  that  of  epilepsy. 


CHAPTER  XXIII. 

Chorea  (St.  Vitus's  Dance). 


Chorea  is  a  disease  of  the  nervous  system,  of  a  convulsive  nature, 
belonging  principally  to  early  life,  and  characterized  by  irregular 
and  spasmodic  movements  of  the  voluntary  muscles.  These  move- 
ments take  place  against  the  will  of  the  patient,  and  are  usually  more 
marked  on  one  side  of  the  body  than  the  other.  They  soon  become 
general,  however,  and  are  increased  by  the  patient's  attempting  to 
exercise  his  will  or  by  emotional  excitement.  The  disease  generally 
begins  very  gradually,  and  is  not  noticed  for  some  time.  Chorea 
has  a  very  intimate  connection  with  acute  rheumatism  and  cardiac 
disease,  and  many  choreic  patients  will  be  found  to  present,  upon 
examination,  an  irregular  action  of  the  heart,  an  anaemic  murmur  at 
the  base  of  the  heart,  or  evidence  of  endocarditis,  pericarditis,  or 
both. 

Rheumatism,  therefore,  and  more  especially  rheumatism  compli- 
cated with  pericarditis  or  endocarditis,  may  be  regarded  as  one  of  the 
prominent  causes  of  chorea.  Among  other  causes  that  may  be  men- 
tioned, sudden  fright  rannks  foremost,  while  anxiety,  overwork,  and 

29 


450  PSYCHOLOGICAL    MEDICINE. 

ill-health  are  also  predisposing  causes.  There  is  also  more  or  less 
paralysis  in  chorea,  which  is  indicated  by  the  loss  of  facial  expression, 
loss  of  speech,  loss  of  the  power  of  swallowing,  dragging  of  the  limbs, 
inability  to  hold  out  the  limb  without  its  falling,  the  readiness  with 
which  patients  become  tired,  and  the  soft,  flaccid  state  of  their  mus- 
cles. Some  degree  of  paralysis  is,  indeed,  quite  a  marked  feature  in 
chorea.  A  child  affected  with  chorea  has  a  dull,  listless  expression, 
avoids  associating  with  other  children,  does  not  evince  the  customary 
interest  in  his  games  and  amusements,  and  becomes  incapable  of 
learning  his  lessons  correctly  or  recollecting  with  any  degree  of  ac- 
curacy. There  is  an  apparent  mental  deficiency  and  there  is  more 
or  less  emotional  disturbance,  excessive  timidity,  capriciousness,  and 
fretfulness.  The  child  is  restless  and  fidgety,  and  ungracefulness  of 
movement  becomes  very  conspicuous.  He  does  not  sit  still  long  in 
one  place,  but  is  constantly  changing  his  position.  He  stumbles  in 
going  about,  up  or  downstairs,  cannot  hold  or  pass  dishes  at  the 
table,  and  generally  knocks  whatever  he  holds  against  something 
else.  The  choreic  movements  usually  begin  on  one  side ;  either 
the  face  or  else  one  hand  and  arm  are  affected.  These  movements 
soon  involve  the  whole  of  one  side,  and,  after  a  few  days  or  weeks, 
extend  to  the  other  side,  involving  the  whole  body.  If  the  attack 
comes  on  during  an  attack  of  rheumatism,  no  prodromal  symptoms 
may  be  seen,  or  if  the  attack  is  induced  by  a  sudden  emotion  the 
onset  is  sudden.  The  convulsions  are  very  peculiar,  and  affect  to  a 
greater  or  less  extent  the  whole  body,  and  are  of  a  disorderly,  not  a 
rhythmical  nature.  They  consist  of  sudden  impulsive  movements. 
They  are  clonic  spasms,  which  are  not  stopped  until  sleep  comes. 
The  speech  is  usually  thick  and  confused,  but  not  lost.  When  the 
patient  endeavors  to  answer  questions  the  convulsive  movements  of 
his  face  and  mouth  become  much  worse,  and  he  finds  it  very  diffi- 
cult to  articulate.  The  words  come  out  with  a  peculiar  drawl  or 
stammer. 

The  difficulty  of  speech  may  depend  upon  the  respiratory  muscles 
and  larynx  being  affected  as  well  as  upon  the  convulsive  action  of  the 
lips  and  tongue.  As  a  result  of  the  respiratory  muscles  being  in- 
volved, the  breath  is  often  drawn  through  the  larynx  with  a  sudden- 
ness that  produces  a  strange,  grunting  noise.  The  convulsive  action 
of  the  muscles  of  the  head  and  neck  is  as  irregular  as  those  of  the 
face,  so  that  the  head  is  jerked  from  one  side  to  the  other.  The  con- 
vulsive movements  of  the  upper  extremity  are  more  striking  than 


CHOREA.  45 1 

those  of  the  lower.  The  shoulders  are  hitched,  the  arms  are  moved 
to  and  from  the  side,  the  forearm  is  pronated,  supinated,  and  flexed, 
and  all  sorts  of  grotesque  movements  executed.  It  is  very  difficult 
for  the  patient  to  hold  a  glass  or  cup  of  liquid  to  the  lips,  and  it  is 
carried  in  all  directions  before  it  reaches  its  intended  destination. 
The  legs  are  affected  like  the  arms,  and  as  soon  as  the  patient  tries 
to  use  them  their  action  becomes  very  jerky  and  uncontrollable. 
The  body  is  twitched  about  very  violently  into  odd  and  eccentric 
attitudes.  In  most  of  the  cases  the  features,  head,  and  neck  are  in 
continual  motion.  The  body  is  doubled  up  and  writhed  around  in 
strange  contortions,  and  the  patient's  condition  is  very  pitiable  to  see. 
The  vacant,  imbecile  aspect  of  the  patient  increases  as  the  disease 
continues,  and  depends  very  much  upon  the  involvement  of  the  mus- 
cles of  expression.  Functional  or  organic  disease  of  the  different 
organs  of  the  body  may  supervene  during  an  attack  of  chorea.  The 
leapings  and  dancings  of  the  religious  enthusiasts,  as  the  "jumpers" 
and  the  "  convulsionnaires,"  should  properly  be  classed  in  the  cate- 
gory of  choreic  affections.  The  people  who,  in  Scotland,  were 
affected  with  the  leaping  ague  and  with  convulsions  and  dancing  fits 
also  come  under  this  head. 

Prognosis. — The  prognosis  is,  in  the  majority  of  cases,  favorable. 
Although  chorea  has  a  long  average  duration,  it  tends  toward  a 
natural  recovery.  The  general  length  of  time  for  an  attack  is  from 
four  to  six  weeks  to  three  or  four  months.  In  a  small  minority  of 
cases  the  disease  lasts  for  many  years,  or  even  a  lifetime.  In  the  few 
fatal  cases,  the  convulsive  paroxysms  become  aggravated  and  the 
spasms  are  incessant.  The  patient  dies  of  exhaustion.  In  the  ma- 
jority of  cases,  recovery  is  thorough  and  complete  if  the  patient  is 
judiciously  treated,  and  the  child  recovers  his  mental  and  physical 
health,  although  occasionally  the  implicated  muscles  remain  feeble, 
and  atrophy  or  contract. 

Pathology. — Several  hypotheses  respecting  the  morbid  anatomy 
and  pathology  of  chorea  have  been  advanced  by  different  observers 
of  more  or  less  ability.  One,  which  originated  with  Dr.  Kirkes, 
and  has  since  been  supported  by  Dr.  Hughlings  Jackson,  adopts  the 
theory  of  embolism.  Dr.  Kirkes  did  not  indicate  what  part  of  the 
nervous  system  he  considered  to  be  the  seat  of  the  disease,  but  said 
that  he  considered  chorea  to  be  "the  result  of  irritation  produced'  in 
the  nerve-centres  by  fine  molecular  particles  of  fibrin,  which  are  set 
free  from  an  inflamed  endocardium  and  washed  by  the  blood  into  the 


452  PSYCHOLOGICAL   MEDICINE. 

cavities  of  these  centres."  Dr.  Hughlings  Jackson,  adopting  and 
enlarging  on  the  theory  of  Dr.  Kirkes,  endeavors  to  show  that  the 
emboH  are  lodged  in  the  vessels  of  the  nerve-tissue  forming  the 
convolutions  near  the  corpus  striatum,  the  blood  supply  of  which  is 
derived  from  the  middle  cerebral  artery,  and  that  a  condition  of  under 
nutrition  is  induced  from  a  diminished  supply  of  blood. 

Dr.  Radcliffe  accepts  Dr.  Hughlings  Jackson's  views  so  far  as 
clinical  evidence  can  be  adduced,  and  says:  "Taking  chorea  of  one 
side  of  the  body,  hemichorea,  as  the  simplest  form  of  chorea,  and 
putting  it  side  by  side  with  hemiplegia,  the  result  of  embolism,  good 
reason  is  found  for  believing  that  the  disorder  of  movement  and  the 
palsy  both  point  to  the  region  of  the  corpus  striatum  as  the  seat  of 
mischief  If  this  be  the  seat  of  mischief  in  hemiplegia,  why  not  in 
hemichorea?  The  muscles  moved  in  hemichorea  are  those  most 
palsied  in  hemiplegia.  In  hemichorea,  as  in  hemiplegia,  the  arm,  as 
a  rule,  is  more  affected  than  the  leg.  In  right  hemichorea,  as  in  right 
hemiplegia,  the  speech  is  generally  very  much  affected.  Again, 
hemichorea  is  always  more  or  less  mixed  up  with  and  sometimes 
ends  in  hemiplegia;  and,  on  the  other  hand,  hemiplegia,  from  various 
causes,  is  not  infrequently  attended  by  chorea  or  movements  of  some 
kind  or  another.  The  fact  that  the  face  is  involved  in  chorea,  shows 
that  the  seat  of  the  disorder  must  be  above  the  spinal  cord.  The 
facts  which  have  been  instanced,  point  to  the  convolutions  near  the 
corpus  striatum  rather  than  in  any  part  of  the  brain  as  the  part 
affected."  Dr.  Broadbent  also  accepts  the  theory  of  embolism  of  the 
fine  vessels  of  the  sensori-motor  ganglia  as  the  principal  cause  of 
chorea.  It  does  not  seem  to  me  that  the  pathological  facts  which 
have  been  elicited  by  morbid  anatomy  justify  the  theory  that  chorea 
is  produced  by,  or  is  dependent  on,  inflammatory  processes  in  the 
brain  or  cord.  Tremor,  convulsion,  and  spasm  do  not  necessarily 
depend  upon  inflammation,  but  may  depend  much  more  readily 
upon  irritation,  and  this  irritability  may,  I  think,  exist  just  as  well 
in  the  thalami  optici,  corpora  quadrigemina,  pons  varolii,  or  in  the 
medulla  or  spinal  cord,  as  in  the  corpora  striata.  The  appearances 
in  the  nervous  system  after  death,  of  embolism  as  a  cause  of  chorea, 
and  the  morbid  appearance  being  located  in  the  sensori-motor  gan- 
glia, are  too  few  to  support  this  theory  successfully,  and  morbid 
appearances  which  are  discovered  do  show  that  all  parts  of  the 
nervous  system  may  become  affected  in  the  course  of  chorea.  The 
cord  is-  very  often  found  affected,  and   particularly  the  posterior 


CHOREA.  453 

columns,  almost  enough  to  suggest  a  relationship  between  this  dis- 
ease and  locomotor  ataxia.  Inflammation  cannot  be  essential  to 
chorea,  for  in  some  cases  there  are  no  traces  of  inflammation.  Ner- 
vous shock  is  very  often  the  real  cause  of  chorea,  and  in  these  cases 
there  would  be  no  lesion  whatever,  unless  it  be  said  that  the  shock 
or  violent  emotion  produces  an  asthenic  or  worn,  irritable  condition 
of  the  sensori-motor  ganglia  of  the  central  nervous  system. 

It  has  been  suggested  that  the  very  great  comparative  frequency 
of  chorea  in  childhood  stands  in  some  relation  with  the  active  func- 
tional state  of  the  sensori-motor  ganglia  during  this  stage  of  exist- 
ence, this  view  perhaps  explaining  the  rarity  of  this  disease  in  infancy 
when  these  centres  have  not  entered  on  active  work,  and  also  in  adult 
life  when  their  period  of  extraordinary  activity  has  passed.  The  most 
reasonable  theory  regarding  the  production  of  chorea  seems  to  the 
writer  to  be  that  it  primarily  proceeds  from  a  morbid  irritability  of 
the  nervous  centres,  and  that  in  the  subsequent  course  of  the  disease 
any  or  all  parts  of  the  nervous  system  may  become  involved  in  an 
inflammatory  process,  but  not  necessarily  so.  In  many  cases  there 
is  an  inherited  irritability  of  the  nervous  system,  which  is  easily 
proved  by  inquiring  into  the  family  history  of  our  patient.  Dr. 
Radcliffe  himself  says,  that  in  the  more  aggravated  cases  of  chorea 
there  is  a  tendency  to  run  into  one  or  other  of  the  inflammatory 
diseases  of  the  brain  and  spinal  cord.  The  general  unilateral  ten- 
dency of  chorea,  which,  so  far  as  it  goes,  is  acknowledged  by  the 
writer  to  point  toward  disease  of  the  crus  cerebri,  corpus  striatum,  or 
cerebral  hemisphere,  is  offset  by  the  involvement  of  the  muscles  of 
the  eyeballs  and  of  the  muscles  supplied  by  the  upper  portions  of  the 
facial  nerves,  which,  as  a  rule,  are  not  involved  in  organic  lesions  of 
this  part.  The  tendency  of  chorea  to  implicate  the  whole  body, 
and  the  muscles  of  deglutition  and  respiration,  is  also  adverse  to  this 
hypothesis,  and,  as  I  have  said,  the  general  resemblance  in  many 
points  of  the  convulsive  movements  to  those  of  locomotor  ataxia 
point  to  a  lesion  in  the  posterior  columns  of  the  cord.  The  objection 
to  this  would  be,  however,  that  if  the  cord  were  affected,  the  disease 
would  not  manifest  a  unilateral  tendency.  Another  very  decided 
objection  to  the  theory  of  embolism  is  the  fact  of  the  absence  of  the 
disordered  movements  during  sleep.  If  embolism  were  present,  owing 
to  plugging  up  of  minute  cerebral  arteries,  the  lesion  would  be  a 
constant  one,  and  if  this  were  the  cause  of  the  convulsive  movements, 
there  could  be  no  remission,  neither  could  they  abruptly  cease,  as 


454  PSYCHOLOGICAL    MEDICINE. 

I  have  seen  them  do  under  treatment.  Another  objection  is,  that 
chorea  is  much  more  frequent  in  girls  than  in  boys,  while  rheuma- 
tism, which,  by  inducing  vegetation  upon  the  valves  of  the  heart, 
is  adduced  to  be  the  cause,  is  most  frequent  in  males.  Again,  the 
embolic  theory  entirely  fails  to  explain  those  cases  which  are  due  to 
fright  or  anxiety,  where  the  heart  is  perfectly  sound,  and  in  my  own 
practice,  chorea  has,  so  far  as  I  have  been  able  to  trace  the  influ- 
ences that  caused  it,  been  very  often  due  merely  to  nervous  shocks, 
w^hich  had  set  up  the  chorea  by  virtue  of  the  sensorial  and  spinal 
irritability  induced  by  the  shock.  I  conclude,  therefore,  that  in  a 
great  many,  and  I  am  inclined  to  think  in  the  majority  of  cases,  that 
chorea  depends  merely  upon  irritability  of  the  hemispheres  and  cord, 
due,  in  very  many  cases,  to  debility  or  deficiency  of  nutritive  vigor 
as  the  predisposing  cause. 

The  symptoms  of  chorea  are  undoubtedly  connected  with  a  morbid 
irritability  of  the  cerebral  convolutions,  the  ganglia  at  the  base  of  the 
brain,  the  pons,  the  medulla,  and  the  spinal  cord.  The  disease  itself 
is  often  associated  with  rheumatism  and  cardiac  disease,  but  it  depends 
upon  hypersemia  and  morbid  irritability  of  the  nervous  centres,  which 
is  produced  by  the  rheumatic  condition,  or  by  mental  or  reflex  ner- 
vous irritability  or  irritation.  There  is  a  general  tendency  to  dilata- 
tion of  the  smaller  vessels,  and  these  arterial  dilatations  are  attended 
with  exudation  into  the  tissues  immediately  surrounding  them,  and 
the  sclerosis,  which  is  thus  induced  in  the  tissues  surrounding  the 
vessels,  explains  the  wasting  of  the  muscles,  rigidity  of  the  limbs, 
and  permanent  paralysis  when  it  supervenes  upon  chorea. 

Dr.  Huntington,  of  Ohio,  described,  in  1872,  an  interesting  form 
of  hereditary  chorea  which  has  prevailed  among  a  few  families  for 
a  long  time,  through  several  generations,  on  the  east  end  of  Long 
Island.  These  families  regard  it  with  horror,  rarely  allude  to  it  ex- 
cept by  necessity,  and  then  speak  of  it  as  ''that  disorder^  Dr.  Pom- 
eroy  speaks  of  the  disease  as  "  attended  generally  by  all  the  symptoms 
of  common  chorea,  only  in  an  aggravated  degree,  hardly  ever  mani- 
festing itself  until  adult  or  middle  life,  and  then  coming  on  gradually 
but  surely,  increasing  by  degrees,  and  often  occupying  years  in  its 
development,  until  the  hapless  sufferer  is  but  a  quivering  wreck  of 
his  former  self.  It  is  as  common,  and  is  indeed,  I  believe,  viore 
common,  among  men  than  women,  while  I  am  not  aware  that  season 
or  complexion  has  any  influence  in  the  matter.  There  are  three 
marked  peculiarities  in  this  disease:    1st,  its  hereditary  nature;  2d, 


CHOREA.  455 

a  tendency  to  insanity  and  suicide;  3d,  its  manifesting  itself  as  a 
grave  disease  only  in  adult  life. 

"  1st.  Of  its  hereditary  nature.  When  either  or  both  of  the  parents 
have  shown  manifestations  of  the  disease,  and  more  especially  when 
these  manifestations  have  been  of  a  serious  nature,  one  or  more  of 
the  offspring  almost  invariably  suffer  from  the  disease  if  they  live  to 
adult  age.  But  if  by  chance  these  children  go  through  life  without 
it,  the  thread  is  broken,  and  the  grandchildren  and  the  great-grand- 
children of  the  original  shakers  may  rest  assured  that  they  are  free 
from  the  disease.  This,  you  will  perceive,  differs  from  the  general 
laws  of  so-called  hereditary  diseases,  as,  for  instance,  in  phthisis  or 
syphilis,  when  one  generation  may  enjoy  entire  immunity  from  their 
dread  ravages,  and  yet,  in  another,  you  find  them  cropping  out  in 
all  their  hideousness.  Unstable  and  whimsical  as  the  disease  may 
be  in  other  respects,  in  this  it  is  firm;  it  never  skips  a  generation  to 
again  manifest  itself  in  another;  once  having  yielded  its  claims,  it 
never  regains  them.  In  all  the  families,  or  nearly  all,  in  which  the 
choreic  taint  exists,  the  nervous  temperament  greatly  preponderates ; 
and  in  my  grandfather's  and  father's  experience,  which,  conjointly, 
cover  a  period  of  seventy-eight  years,  nervous  excitement  in  a  marked 
degree  almost  invariably  attends  upon  every  disease  these  people 
may  suffer  from,  although  they  may  not  when  in  health  be  over- 
nervous. 

"  2d.  The  tendency  to  insanity,  and  sometimes  that  form  of  insanity 
which  leads  to  suicide,  is  marked.  I  know  of  several  instances  of 
suicide  of  people  suffering  from  this  form  of  chorea,  or  who  belonged 
to  families  in  which  the  disease  existed.  As  the  disease  progresses, 
the  mind  becomes  more  or  less  impaired,  in  many  amounting  to 
insanity;  while,  in  others,  mind  and  body  both  gradually  fail  until 
death  relieves  them  of  their  sufferings. 

"  3.  Its  third  peculiarity  is  its  coming  on,  at  least  as  a  grave  disease, 
only  in  adult  life.  I  do  not  know  of  a  single  case  that  has  shown 
any  marked  signs  of  chorea  before  the  age  of  thirty  or  forty  years,, 
while  those  who  pass  the  fortieth  year  without  symptoms  of  the  dis- 
ease are  seldom  attacked.  It  begins  as  an  ordinary  chorea  might 
begin,  by  the  irregular  and  spasmodic  action  of  certain  muscles,  as 
of  the  face  and  arms,  etc.  These  movements  gradually  increase, 
when  muscles  hitherto  unaffected  take  on  the  spasmodic  action,  until 
every  muscle  in  the  body  becomes  affected  (excepting  the  involun- 
tary ones),  and  the  poor  patient  presents  a  spectacle  which  is  anything 


456  PSYCHOLOGICAL    MEDICINE. 

but  pleasing  to  witness.  I  have  never  known  a  recovery,  or  even  an 
amelioration  of  symptoms  in  this  form  of  chorea;  when  once  it  be- 
gins it  clings  to  the  bitter  end.  No  treatment  seems  to  be  of  any 
avail."  Dr.  Huntingdon  says  that  ordinary  chorea  is  of  exceedingly 
rare  occurrence  in  this  section,  and  he  does  not  remember  a  single 
instance  of  its  occurring  in  his  father's  practice.  He  suggests  noth- 
ing as  to  its  pathology.  I  have  met  with  one  instance  of  chorea 
minor  in  a  father,  son  and  grandson,  but  it  acted  very  differently 
from  the  form  described  above.  In  the  son  and  grandson  it  appeared 
in  early  life,  and  I  do  not  see  that  it  has  ever  assumed  grave  propor- 
tions in  either,  although  the  nervous  system  preponderates  in  all. 

Treatmoit. — There  are  few  diseases  of  the  nervous  system  so  easy 
to  treat  successfully  as  chorea  in  its  ordinary  form,  and  few  in  which 
so  many  remedies  have  been  employed.  Dr.  Sydenham  says,  "  For- 
asmuch as  this  disease  seems  to  me  to  proceed  from  some  humor 
rushing  in  upon  the  nerves,  which  provokes  such  preternatural  mo- 
tions, I  think  the  curative  indications  are  first  to  be  directed  to  the 
lessening  of  those  humors  by  bleeding  and  purging,  and  then  to  the 
strengthening  the  genus  nervosum,  in  order  to  which  I  use  this 
method :  I  take  seven  ounces  of  blood  from  the  arm,  more  or  less, 
according  to  the  age  of  the  patient,"  etc.,  etc.  This  old  treatment 
has  been  abandoned,  although  Sir  Thomas  Watson  recommends  local 
bleeding  when  there  is  a  fixed  pain  in  the  head,  and  he  also  uses  iron 
which  is  the  favorite  medicine  in  cases  of  chorea,  with  English  prac- 
titioners and  Dr.  Elliotson  especially ;  forty  cases  of  cure  being  re- 
ported by  this  mode  of  treatment. 

It  has  appeared  to  me  that  the  good  accruing  from  the  use  of  iron 
is  that  obtained  from  improving  the  general  health  of  the  patient, 
and  in  this  way,  as  iron  is  an  important  tonic,  it  undoubtedly  does 
good,  although  I  do  not  think  it  should  be  regarded  as  exerting  any 
specific  action  in  chorea;  sulphate  of  zinc  in  increasing  doses,  com- 
mencing with  one  grain  three  times  a  day  has  been  employed. 
Strychnia  has  been  employed,  especially  in  France,  where  it  was  in- 
troduced as  a  remedy  for  chorea  by  Trousseau,  who  commenced  with 
doses  of  2V  in  children,  gradually  increasing  it  until  the  full  physiologi- 
cal effects  of  strychnia  were  produced,  maintaining  them  for  awhile. 
The  iodide  and  bromide  of  potassium  have  also  been  used,  but  with- 
out practical  results.  The  various  narcotics  have  been  tried,  with  ho 
good  results.  In  my  own  treatment  of  these  cases  I  endeavor  to 
give  the  nervous  system  rest  and  nutrition.     I  obtain  the  former  by 


CHOREA,  457 

avoidance  of  excitement,  early  hours,  and  the  calmative  influence  of 
warm  baths  at  bed-time ;  the  latter  by  using  phosphorated  cod-liver 
oil,  or  the  oil  in  connection  with  the  phosphide  of  zinc,  tV  grain,  in 
pill  three  times  a  day.  Gentle  gymnastic  exercises  are  very  valuable, 
and  should  by  no  means  be  neglected.  My  favorite  remedy,  and  the 
one  which  seems  to  be  the  nearest  to  a  specific  in  chorea  is  arsenic, 
which  I  use  hypodermically  in  the  shape  of  Fowler's  solution.  I 
use  a  mixture  of  equal  parts  of  Fowler's  solution  and  water,  to  avoid 
any  local  irritation  which  might  be  produced  by  the  undiluted  solu- 
tion. In  children  I  rarely  see  any  want  of  toleration  of  the  drug  in 
the  system,  and  rarely  also,  in  those  of  older  years.  I  have  found 
that  very  rapid  improvement  generally  takes  place  under  this  treat- 
ment from  the  first,  and  my  patients  gain  flesh.  I  generally  use 
electricity  in  the  form  specially  indicated  in  individual  cases  as  an  im- 
portant adjuvant  in  improving  the  whole  nervous  and  physical  con- 
dition of  my  patients.  I  commence  with  three  minims  of  Fowler's 
solution  and  inject,  subcutaneously,  for  a  week,  every  other  day,  and 
in  the  second  week  increase  the  dose  to  five  minims  every  other  day, 
increasing  two  minims  each  week,  and  in  a  month  or  six  weeks  a 
cure  will  be  obtained,  while  in  old  cases  sixty  or  seventy  days  may 
elapse  before  a  cure  is  complete.  Marked  improvement  is  always 
noticed  from  the  first  by  this  plan  of  treatment. 

By  this  method  the  gastric  disturbances  which  are  produced  when 
the  medicine  is  given  by  the  stomach  are  avoided,  and  the  good  re- 
sults which  we  can  obtain  are  very  much  more  rapid.  I  advise  this 
plan  of  treatment  in  chorea  by  general  practitioners,  believing  that 
they  will  find  it,  as  I  have,  most  efficacious. 

In  1849  there  was  reported  in  the  London  Medical  Gazette,  of  April 
27th,  the  second  Lumleian  lecture,  by  Dr.  R.  B.  Todd,  of  England, 
on  chorea.  Many  of  the  remarks  there  found  are  equally  sound  to- 
day. He  remarks  that  the  most  common  exciting  cause  of  chorea 
is  fright  or  strong  mental  emotion.  He  cites  a  case  of  one  of  his 
patients,  a  girl,  nineteen  years  of  age,  who  was  rudely  accosted  and 
laid  hold  of  in  the  street  by  a  person  under  the  garb  of  a  gentleman, 
and  she  became  greatly  alarmed  and  escaped  to  the  house  of  a  rela- 
tion. Next  morning  the  symptoms  of  chorea  showed  themselves. 
In  this  lecture  Dr.  Todd  drew  the  following  conclusions  respecting 
the  pathology,  and  considering  how  long  ago  this  was,  we  must  ad- 
mit that  they  were  peculiarly  good  and  correct : 


458  PSYCHOLOGICAL    MEDICINE. 

1.  That  chorea  is  a  disease  occurring  at  a  time  when  the  nutrition  of  the  brain  is 
passing,  as  it  were,  through  a  state  of  transition,  from  that  of  infancy  or  verj'  early 
childhood,  to  that  of  the  adult  period,  when  that  organ  is  peculiarly  prone  to  suffer  from 
mental  shock,  or  other  causes  of  disturbance  of  the  system,  and  more  especially  when 
the  blood  is  in  an  unhealthy  state,  deficient  in  some  of  its  staminal  principles,  or  con- 
taining some  morbid  element. 

2.  That  the  part  of  the  brain  mainly  affected  is  the  centre  of  emotion,  but  that  the 
extent  to  which  it  suffers  is  sometimes  limited  to  one  side  of  that  centre,  sometimes  to 
both,  again  extending  to  the  cerebellum  or  to  the  corpora  striata  or  optic  thalami. 

3.  That  the  nature  of  the  cerebral  affection  is  one  of  weakened  nutrition,  with  some 
degree  of  irritation;  as  poor  blood,  rendered  perhaps  impure  by  the  presence  of  the 
matter  of  scrofula,  or  of  rheumatism,  or  by  some  morbid  matter  peculiar  to  chorea,  ex- 
cites the  nervous  battery,  and  causes  it  to  generate  its  force  feebly  and  irregularly.  The 
centre  of  emotion  thus  feebly  excited,  and  irritated  by  the  presence  of  an  abnormal  ingre- 
dient in  the  blood,  extends  its  feeble  and  irregular  polarity  to  that  portion  of  the  centre 
of  implantation  of  the  nerves  which,  as  the  polar  slate  of  the  conductors  of  the  battery 
is  regulated  by  that  of  the  battery  itself,  exhibit  the  same  enfeebled  polarity  as  the  centre 
in  which  they  are  implanted. 

Lastly.  The  disease  is  one  of  depraved  general  nutrition,  which  must  be  set  right 
before  these  symptoms  which  arise  out  of  the  local  disturbances  can  be  removed ;  and 
this  is  the  point  of  practical  interest  which  must  regulate  our  treatment  of  the  disease. 
These  conclusions,  respecting  the  pathology  of  chorea,  receive  confirmation  from  the 
facts  to  which  I  have  already  alluded — namely,  that  choreic  movements  occur  in  certain 
gouty  states,  and  also  in  white  softening  of  the  brain  arising  from  diseased  arteries. 
Under  both  these  conditions  the  nutrition  of  the  brain,  as  well  as  that  of  the  nerve  and 
muscles,  must  be  depraved  and  weakened ;  depraved,  especially  in  the  former  instance, 
by  the  matter  or  poison  of  gout;   weakened  in  both. 

Dr.  Todd  speaks  of  the  treatment  as  one  which  should  be  ehmi- 
natory  and  corrective  of  the  various  secretions,  and  at  the  same  time 
tonic  and  bracing  to  the  nervous  system,  by  the  free  application  of 
cold  water  to  the  surface,  by  a  nourishing  diet,  and  by  chalybeates, 
quinine,  and  other  metallic  tonics.    He  also  recommended  galvanism. 

On  the  treatment  of  chorea  Dr.  Samuel  Wilks,  physician  to  Guy's 
Hospital,  says  : 

It  might  be  thought  bj'  the  inexperienced  that  those  drugs  which  exert  a  physiologi- 
cal action  over  the  nervous  system  would  be  those  which  would  arrest  the  complaint 
known  as  chorea,  but,  as  a  matter  of  fact,  this  is  not  the  case,  so  that  I  have  almost 
given  up  looking  for  a  remedy  in  the  direction  of  this  class  of  medicines.  I  do 
not  despair,  however,  of  finding  some  drug  which  might  counteract  that  morbid  condi- 
tion of  nervous  system  which  is  present  in  very  bad  cases,  but  in  the  absence  of  such 
remedy  our  ordinary  curative  means  are  of  little  avail,  seeing  that  they  can  act  only 
slowly  and  tend  to  produce  a  change  long  after  the  time  at  which  the  acute  form 
of  the  disease  would  prove  fatal.  In  these  very  severe  and  bad  cases  we  can  only  hope 
to  preserve  the  life  of  the  patient  sufficiently  long  for  the  most  approved  tonic  remedies 
to  act.  For  example,  in  such  cases  as  I  mentioned  just  now  of  children  suffering  from 
acute  chorea  induced  by  fright,  a  fatal  termination  may  occur  in  a  few  days,  and  in  these 


CHOREA.  459 

the  direct  sedatives  are  suggested.  Morphia,  as  far  as  I  have  seen,  is  useless.  I  can  call 
to  mind  two  cases  vi'here  large  doses  were  given,  but  the  effect  was  only  transitory.  The 
same  with  chloroform  ;  the  vapor  produces  but  a  temporary  tranquillizing  effect,  and  our 
experience  of  it  is  not  encouraging  either  in  chorea  or  in  the  allied  disorders,  tetanus  and 
hydrophobia.  I  have  never  seen  strychnia  of  any  use  in  the  acute  affection ;  and  the 
same  of  belladonna  and  conia.  In  the  less  severe  cases  it  is  possible  that  one  or  two  of 
these  medicines  may  be  useful,  but  I  feel  convinced  that  the  class  of  medicines  of  which 
I  speak — those  which  have  a  physiological  action  on  the  nervous  system — are  far  less 
efficacious  than  the  metallic  tonics.  It  would  seem  that  in  order  to  produce  a  cure,  a 
bracing  up  or  restoration  of  the  original  nerve-power  is  necessary,  and  that  the  mere  sub- 
dual of  symptoms  in  no  way  tends  to  cure  the  complaint.  When  I  say  this  I  speak  with 
some  little  hesitation  of  the  effects  of  belladonna  and  conium,  both  of  which  remedies 
I  have  seen  apparently  useful.  I  remember,  when  at  Paris  some  years  ago,  hearing  Trous- 
seau give  a  lecture  on  this  disease  and  warmly  recommend  belladonna.  On  another  occa- 
sion he  was  declaring  that  there  was  no  drug  in  the  Pharmacopoeia  equal  to  strong  coffee, 
and  on  a  third  occasion  he  was  vaunting  the  new  gymnasium  at  the  Hospital  for  Sick 
Children  as  the  best  therapeutic  agent  he  knew.  I  mention  this  to  show  you  that  there 
really  is  no  specific  treatment  for  the  disease.  I  might  say  that  we  thought  we  saw  some 
benefit  in  one  case  after  the  use  of  cannabis  indica,  but  none  whatever  in  four  cases  in 
which  we  tried  the  physostigma. 

I  believe  I  can  tell  you  something  very  positive  about  the  treatment  of  chorea,  and  I 
only  wish  I  was  enabled  to  make  the  same  boast  in  reference  to  some  other  diseases. 
Many  years  ago,  seeing  that  every  medicine  in  the  Pharmacopoeia  as  well  as  several  others 
out  of  it,  were  said  to  be  equal  to  the  cure  of  chorea,  I  determined  to  watch  the  disease 
untrammelled  by  medicine,  and  I  found  that  in  many  cases  a  speedy  recovery  took  place 
without  the  administration  of  any  medicine  whatever.  The  cases  which  did  best  were 
the  severe  ones,  excepting  always  those  w^.icli  were  of  the  most  violent  and  acute  de- 
scription. The  first  case  which  I  watched  was  a  little  girl  who  had  severe  chorea ;  she 
was  too  bad  to  be  able  to  stand,  and  was  obliged  to  have  sideboards  to  her  bed  to  pre- 
vent her  wriggling  out  of  it.  This  child  began  to  improve  in  a  day  or  two,  and  went 
out  well  in  a  month.  This  is  only  one  example  of  several  of  the  same  kind.  I  take  it 
that  the  patient,  being  subject  to  constant  excitement  or  improper  treatment  at  her  own 
home,  has  her  disease  there  perpetuated,  whereas,  when  brought  to  the  hospital,  being 
under  the  influence  of  strangers  who  endeavor  to  make  her  suppress  the  movements, 
and  by  the  additional  advantage  of  good  living,  she  begins  to  recover.  I  should  say 
that  a  weakened  condition  of  the  nervous  centres  being  at  the  root  of  the  malady,  good 
nourishment  and  the  tonic  plan  are  necessary.  After  having  learned  the  fact  that  the 
tendency  of  the  disease  is  towards  recovery  as  soon  as  all  the  circumstances  which  for- 
merly surrounded  the  patient  were  removed,  I  soon  afterwards  learned  that  the  cure  is 
expedited  by  tonic  medicines  of  the  mineral  kind,  and  this  is  the  experience  of  the  ma- 
jority of  the  profession.  I  have  put  the  treatment  before  you  in  this  way  to  prevent  you 
supposing  that  such  remedies  as  iron  or  zinc  act  in  any  specific  manner;  they  are  useful, 
but  operate  as  nervine  tonics.  I  believe  Dr.  Elliotson,  many  years  ago,  acquired  great 
fame  by  his  success  in  the  treatment  of  chorea,  his  remedy,  as  you  know,  being  the  red 
oxide  of  iron.  We  still  give  it,  and  it  is  one  of  the  best  of  remedies  ;  our  children  very 
willingly  take  half-drachm  doses  in  treacle.  Probably  an  equally  favorite  remedy  here 
is  the  zinc — in  fact,  it  is  the  medicine  most  commonly  given,  beginning  with  grain  doses 
and  increasing  to  any  amount,  as  a  scruple  three  times  daily.  A  favorite  remedy  of 
my  late  colleague  Dr.  Hughes  was  rhubarb  steeped  in  port  wine ;  the  children  were 


460  PSYCHOLOGICAL    MEDICINE. 

thus  well  kept  up  at  the  same  time  that  the  stomach  and  bowels  were  improved  in  con- 
dition. 

In  very  chronic  cases,  and  those  where  a  part  of  the  body  only  is  affected,  medicines 
are  of  little  use.  In  some  of  these  electricity  has  sometimes  been  curative ;  in  some 
cases  shower-baths  have  acted  with  the  best  success.  One  writer  has  advocated  the  use 
of  liniments,  as  of  chloroform,  to  the  spine.  Often  nothing  less  than  a  thorough  change 
of  scene  will  suffice  to  break  the  habit.  If  this  opportunity  do  not  occur,  gymnastic  ex- 
ercises are  of  use.  They  not  only  strengthen  the  muscles  and  nerves,  but  thej'  break  tlie 
bad  habit;  they  convert,  in  fact,  an  irregular  movement  into  a  regular  one.  If  the  arms 
are  constantly  moving,  and  are  then  employed  in  grasping  a  beam  for  swinging,  a  new 
and  altered  condition  of  the  whole  machineiy  accrues,  and  in  time  the  habitual  ir- 
regular actions  are  worn  out.  I  am  sorry  that  we  have  not  a  gymnasium  here,  and 
therefore,  all  I  am  able  to  do  is  to  order  my  patients  a  skipping  rope.  I  believe  the  only 
method  by  which  chorea,  which  at  one  time  prevailed  in  religious  houses,  was  sometimes 
able  to  be  cured  was  by  making  the  ladies  dance  to  the  notes  of  music. 

On  the  use  of  Indian  hemp  in  chorea,  Dr.  Douglas,  Vice-Presi- 
dent of  the  Medico-Chirurgical  Society  of  Edinburgh,  says : 

Dr.  Russell  Reynolds,  who  writes  one  of  the  most  recent,  and  one  of  the  best  exposi- 
tions of  the  value  of  this  remedy,  tells  us,  as  the  result  of  a  manifestly  practical  and 
thoughtful  experience,  that  "  it  is  a  soporific,  anodyne,  and  antispasmodic  ;  and  that  it  re- 
lieves pain  and  spasm ;  that  it  does  nc^t  leave  behind  it  headache  or  vertigo ;  nor  does  it 
impair  the  appetite,  nor  confine  the  bowels." 

[The  patient,  a  girl  13  years  of  age,  was  admitted  into  the  Chalmers  Hospital  on  the 
15th  of  October  last.  A  month  previous  to  admission  she  had  been  taken  with  an  attack 
of  rheumatic  fever.  No  sjonptoms  of  cardiac  inflammation  occurred.  The  choreal  ac- 
tion had  existed  about  a  fortnight.] 

During  the  day  immediately  succeeding  her  admission,  a  rapid  change  occuiTed  in  the 
degree  of  the  choreal  movements,  and  in  the  state  of  the  heart's  action.  The  latter  be- 
came so  disturbed,  feeble,  and  excited,  with  feeble  arterial  pulse,  as  to  cause  serious  anx- 
iety' for  the  safety  of  the  patient,  and  at  the  same  time  the  choreic  agitation  increased 
with  such  violent  restlessness  and  rolling  in  bed  that  excoriations  occurred  over  the 
sacrum  and  both  nates,  while  contortion  of  the  features  and  tossing  of  the  extremities, 
especially  when  their  movement  was  attempted,  continued  excessive.  The  articular  effects 
of  rheumatism  decreased,  temperature  became  more  natural,  the  urine  healthy,  but  the 
bowels  became  torpid.  The  arsenic  was  persevered  with,  and  a  few  30-grain  doses  of 
bromide  of  potassium  were  given.  Each  dose  was  followed  by  a  short  period  of  qui- 
escence, but,  on  the  20th,  the  excitement  of  the  heart's  action  became  so  alarming  that 
25-minim  doses  of  tincture  of  India  hemp  were  administered,  followed  by  apparently 
marked  but  only  transient  abatement  of  the  spasmodic  movement,  which,  as  Dr.  Hogg, 
the  resident  physician,  reported,  seemed  to  recur  subsequently  with  increasing  and  dis- 
tressing severity. 

On  the  following  day — that  is,  the  sixth  of  her  residence  in  the  hospital — her  condi- 
tion seemed  desperate,  chiefly  on  account  of  the  protracted  and  uncontrollable  hurry  of 
the  heart's  action.  She  was  ordered  to  have  six  minims  of  the  tincture  cannabis  every 
hour,  the  arsenic  and  other  remedies  being  intermitted.  The  bowels  were  now  well  reg- 
ulated, the  excoriations  of  the  back  and  nates  had  increased  so  as  to  form  superficial 
sloughs  of  considerable  extent,  the  pulse  was  small  and  so  rapid  as  not  to  be  counted, 
and  the  heart's  action  was  still  feeble,  rapid  and  disturbed.     She  had  four  ounces  of 


CHOREA,  461 

brandy  per  day.  On  the  following  day,  having  had  twenty  doses  of  the  tincture,  there 
was  a  marked  and  increasing  improvement.  The  violence  of  the  tossing  and  rolling  had 
diminished  materially,  though  still  it  was  necessary  to  have  her  secured  in  bed  to  prevent 
her  falling  or  rolling  over.  From  this  time  till  the  15th  day  of  her  residence  in  the  hos- 
pital, the  tincture  was  administered  from  hour  to  hour,  and  she  continued  to  make  daily 
and  progressive  improvement.  At  that  date  (the  28th)  she  had  been  free  of  all  the  more 
violent  spasmodic  movements  for  two  days  ;  the  heart's  action  was  quiet,  pulse  about 
80,  appetite  good,  bowels  regular.  She  still  presented  a  degree  of  the  peculiar  grimace, 
with  awkvvrardness  in  protruding  the  tongue,  and  in  movement  of  the  arms  and  hands. 
There  was  a  great  mental  lethargy,  with  languor  and  exhaustion,  which  made  it  impossible 
for  her  to  be  out  of  bed. 

The  tincture  of  hemp  was  now  discontinued  and  arsenical  solution  in  four-minim  doses 
resumed. 

The  subsequent  progress  of  the  case,  though  tedious,  and  so  far  disappointing,  may  be 
told  in  a  few  sentences.  On  the  1st  of  November,  and  on  several  occasions  during  the 
rest  of  that  month,  there  occurred  a  renewal  of  the  choreal  state,  which  had  not,  indeed, 
absolutely  disappeared,  though  it  was  often  so  trivial,  and  even  absent,  as  to  encourage  the 
hope  of  an  early  recovery.  Arsenic  was  perseveringly  employed,  with  a  carefully-reg- 
ulated diet  and  general  management,  but  on  each  occasion,  of  which  three  were  noted, 
when  an  exacerbation  of  the  choreic  condition  arose,  a  marked  abatement  of  the  muscu- 
lar action  resulted  from  the  administration  of  small  and  hourly-repeated  doses  of  tincture 
of  hemp,  relief  sometimes  arising  so  speedily  as  within  six  or  eight  hours.  On  one  occa- 
sion the  improvement  was  not  detected  for  three  or  four  days. 

In  the  beginning  of  December,  rheumatic  symptoms  recurred,  with  slight  febrile  action 
and  articular  pains,  and  renewal  of  choreic  agitation.  At  the  same  time,  marked  excite- 
ment of  the  heart's  action  was  renewed,  and  now,  for  the  first  time,  a  faint,  soft  diastolic 
murmur,  indicative  of  aortic  regurgitation,  was  with  difficulty  perceived.  A  weak  solu- 
tion of  acetate  and  nitrate  of  potash  was  administered,  and  grain  doses  of  opium  four  or 
five  times  in  twenty-four  hours.  Pain  and  fever  abated,  but  not  the  spasmodic  move- 
ment, and  on  the  third  day  afterwards  six-minim  doses  of  tincture  of  hemp  were  given 
every  two  hours,  followed  by  an  immediate  decrease  of  the  chorea,  which  at  once  de- 
clined to  the  slightest  degree  in  two  or  three  days. 

The  patient  now  presented  more  marked  indications  of  returning  health.  The  state 
of  mental  lethargy  into  which  she  had  early  lapsed  was  now  passing  off;  her  appetite  was 
revived,  and  on  the  20th  December  she  was  able  to  be  out  of  bed  and  to  walk  with  assis- 
tance. Small  doses  of  the  iodide  of  potassium  with  the  infusion  of  quassia  were  given, 
and  improvement  went  on  uninterruptedly ;  she  did  not,  however,  cast  off  the  choreic 
jerk  and  awkwardness  till  the  second  week  of  January,  1869.  She  has  since  had  a 
very  comfortable  convalescence,  but  the  diastolic  murmur  noted  above  continues  strongly 
developed. 

The  impression  which  the  case  leaves  on  my  mind  is,  that  cannabis  has  a  peculiar  value 
and  power  in  controlling  the  irregular  movements  of  chorea,  which  ever  and  again  are 
terribly  distressing,  and  possibly  even  dangerous,  to  the  patient ;  and  it  would  be  of  no 
small  moment  to  determine  the  extent  and  limit  of  its  influence,  and  to  ascertain  whether 
dr  not  choreic  action,  even  in  slighter  cases,  might  not  be  moderated  by  this  remedy. 

As  to  the  mode  of  administering  the  remedy,  small  and  frequent  doses  proved  both 
safe  and  effective,  and  great  advantage  appeared  to  arise  from  increasing  the  frequency 
of  the  dose  rather  than  its  amount.  Believing,  as  I  do,  that  cannabis  indica  is  a  remedial 
agent  of  value  in  many  and  various  maladies,  I  am  prepared  to  recommend  this  mode  of 
seeking  its  eifects  by  frequent  rather  than  by  larger  doses  at  longer  intervals.     Such  a 


462  PSYCHOLOGICAL    MEDICINE. 

mode  of  prescribing  it  has  not  been  usual ;  but  I  find,  quoted  from  an  American  source, 
the  account  of  a  case  of  hiccup  treated  in  this  way  by  eight-drop  doses  of  a  fluid  extract, 
administered  hour  by  hour,  in  which  recovery  from  an  attack  that  had  defied  treatment 
for  five  days  took  place  in  a  few  hours. 


CHAPTER  XXIV. 


VERTIGO. 


Vertigo  consists  in  the  sensation  of  giddiness  or  moving,  or  the 
appearance  of  moving,  of  external  objects  when  there  is  no  real  ex- 
istence of  movement. 

The  patient  is  very  much  distressed  by  a  sense  of  a  want  of  equi- 
librium, of  falling  or  turning  round,  and  the  things  which  are  about 
him  appear  to  swim  and  oscillate  before  his  vision.  The  condition 
varies  from  a  slight  sense  of  unsteadiness  or  oscillation  to  such  a  de- 
gree of  vertigo  as  altogether  destroys  equilibrium,  and  the  patient 
falls  to  the  ground  unless  he  takes  hold  of  something  to  prevent  him 
from  falling.  This  sensation  is  the  most  powerful  when  the  patient 
is  standing  up,  but  may  come  on  while  he  is  lying  down,  and  even 
when  the  eyes  are  shut.  Patients  suffering  from  vertigo  complain  of 
tinnitus  aurium  (various  kinds  of  noises),  which,  although  nearly 
always  present  until  recovery,  is  more  pronounced  during  the  attacks 
of  vertigo.  The  cause  of  vertigo  is  primarily  a  disordered  and  dis- 
turbed circulation  in  the  brain,  which  is  proved  by  the  fact  that  it 
attends  both  cerebral  ansemia  and  cerebral  hyperemia.  It  is  very 
often  dependent  upon  a  disordered  state  of  the  blood  itself,  as  in  fever 
and  in  various  inflammatory  diseases.  It  may  also  appear  as  the 
result  of  blood-poisoning,  from  malarial  poisoning,  and  the  injurious 
effects  of  tobacco  and  intoxication.  It  may  be  associated  with — and 
generally  is  connected  with — epilepsy,  convulsions,  and  organic 
lesion  in  the  body.  It  is  very  often  dependent  upon  functional  dis- 
orders of  the  stomach.  It  attends  disease  of  the  cerebellum  and  of 
the  cerebro-spinal  system.  Diseases  of  the  eye  and  ear  are  also 
attended  very^  frequently  with  vertigo.  The  vertigo  appears  in  the 
affections  of  the  eye,  when  its  muscles  are  involved,  and  especially 


VERTIGO.  463 

in  afifections  of  the  ear,  when  there  is  disease  of  the  semicircular 
canals.  In  disseminated  sclerosis  the  vertigo  is  an  early  symptom, 
and  is  gyratory,  and  comes  on  in  paroxysms,  and  is  occasionally 
almost  continuous. 

The  differential  diagnosis  between  ordinary  vertigo  dependent 
upon  simple  disordered  circulation  of  the  brain  or  functional  disorders 
of  the  stomach  and  the  vertigo  of  disseminated  sclerosis  would  be 
that  in  the  latter  case  our  patient  would  present  rhythmical  tremors, 
affections  of  the  eyes,  defect  of  speech,  and  an  early  paresis  of  the 
limbs.  Contraction  of  the  limbs  and  changes  in  the  mental  condi- 
tion and  expression  also  are  seen  in  sclerosis.  In  tumors  of  the  brain 
vertigo  is  one  of  the  most  constant  symptoms,  and  it  is  associated 
with  headache  and  vomiting.  In  order  to  understand  the  cause  of 
vertigo  in  any  given  case,  we  must  carefully  study  the  accompanying 
symptoms.  The  suppression  of  either  a  haemorrhage  of  long  stand- 
ing or  of  a  chronic  skin  disease  are  both  common  causes  of  vertigo. 
Vertigo,  then,  may  depend  on  functional  disorders  of  the  viscera,  or 
upon  organic  or  functional  brain  disease,  or  blood-poisoning,  or  it 
may  depend  upon  a  weak  heart  with  a  dilated  right  ventricle. 

The  most  common  kind  of  vertigo  which  we  meet  with  in  practice 
arises  from  disordered  digestion,  and  can  be  referred  to  the  stomach, 
or  functional  derangement  of  the  liver,  or  may  occur  suddenly,  either 
at  day  or  night,  and  is  very  distressing  to  the  patient  from  its 
violence. 

This  variety  depends  upon  a  sudden  arrest  of  the  process  of  di- 
gestion, which  produces  a  temporary  functional  disturbance  of  the 
brain  and  its  circulation.  The  utmost  that  any  of  my  patients  have 
ever  complained  of  has  been  a  mere  uneasiness  over  the  epigastric 
region.  They  have  denied  the  presence  of  pain  after  food  has  been 
taken  into  the  stomach.  In  women,  we  often  find  associated  with 
this  form  of  vertigo,  leucorrhoea,  menorrhagia,  obstinate  constipa- 
tion, and  amenorrhoea,  and  the  fact  that  after  these  diseases  are  re- 
lieved the  vertigo  remains  proves  the  stomachal  orgin  of  it.  In  this 
form  of  vertigo  we  never  find  a  loss  of  consciousness,  as  we  may 
when  it  depends  on  organic  brain  lesions.  The  patient  sometimes 
is  perfectly  free  from  it ;  an  empty  stomach  and  excitement  make  it 
worse.  Stimulants  relieve  it,  and  closing  the  eye  so  as  to  shut  out 
all  external  objects  relieves  it.  Although  a  few  patients  complain 
of  a  constant  slight  sense  of  vertigo,  most  of  them  will  give  a  his- 
tory of  several  successive  daily  attacks,  lasting  generally  a  few  min- 


464  PSYCHOLOGICAL   MEDICINE. 

utes,  accompanied  by  a  distressing  heaviness  in  the  head.  In  hard 
drinkers,  we  often  find  the  vertigo  may  last  for  days,  and  render  them 
unable  to  move.  The  disease  depends,  in  these  cases,  upon  struc- 
tural alteration  of  the  capillaries,  and  the  symptoms  present  are  nau- 
sea and  aversion  to  food.  This  form  of  vertigo  of  which  we  have 
been  speaking — that  arising  from  disordered  digestion — may  be 
effectually  relieved  by  the  following  treatment :  The  patient,  if  a 
man,  must  be  free  from  the  care  and  anxiety  of  business.  Upon 
arising  in  the  morning,  a  cold  sponge  or  plunge  bath,  with  subse- 
quent friction  on  the  surface  of  the  body  with  a  Turkish  towel.  No 
malt  liquor  must  be  indulged  in.  The  diet  must  be  plain,  regular, 
and  well  masticated.  Vichy,  with  a  very  little  brandy,  may  be  used 
as  a  drink.  The  patient  must  retire  early,  and  sleep  in  a  large,  cool 
room.     The  following  may  be  taken  before  meals  : 

R.— Pulv.  rhei,  .         .         .         .         .         .         .         ^         .         .  5J. 

Sodse  carbonat., .         .         .  gij. 

Pulv.  gentian,    .         .         .         .         .         .         .         .         .         •  ^^• 

Aquae  menth.  pip., 

Aquae  dest.,       .         .         .         • aa  3iij. 

M.  S. — Tablespoonful  thrice  daily  before  meals. 

Or,  five  drops  of  the  tincture  of  nux  vomica,  a  remedy  which  is  an 
efficient  tonic  to  the  whole  gastro-intestinal  tract,  may  be  given  in  a 
little  water  before  each  meal.  In  some  cases,  an  examination  of  the 
urine  microscopically  will  reveal  oxalate  of  lime,  which  produces 
oxaluria,  and  may  give  rise  to  vertigo.  This  can  be  readily  relieved 
by  fifteen  drops  of  dilute  nitro-muriatic  acid,  given  in  water  thrice 
daily  before  meals.  In  individual  cases  with  individual  complica- 
tions, relieve  these  first  and  improve  the  general  nutrition,  and  then 
direct  the  treatment  directly  to  the  vertigo. 

A  great  many  cases  of  vertigo  depend  for  their  cause  upon  drink 
and  mental  anxiety.  These  attacks  are  of  comparatively  short  dura- 
tion, and  occur  every  few  hours  or  days.  At  first  the  sensations  are 
referred  to  external  objects,  and  occur  only  when  the  patient  is  mov- 
ing. As  it  becomes  more  frequent,  there  is  an  internal  feeling  of 
dizziness,  which  lying  down  generally  relieves.  In  the  male,  it  is 
associated  with  stomach  disorders,  and  in  females,  with  menstrual 
disorders.  The  principal  symptoms  are  want  of  clearness  of  intel- 
lect, incapability  of  sustained  mental  effort,  with  headache.  There 
may  be,  in  cases  where  oxaluria  is  present,  great  irritability  of  tem- 
per, depression  of  spirits,  sleeplessness,  and  impaired  nutrition. 


VERTIGO.  465 

A  great  many  cases  of  vertigo  are  connected  with  lithaemia,  and 
Dr.  Da  Costa,  of  Philadelphia,  in  his  able  monograph  on  The  Nerv- 
ous Symptoms  of  Lithcemiay  ranks  it  as  one  of  the  principal  nervous 
symptoms  of  that  state  which  is  characterized  by  the  abundance  of 
lithic  acid  or  lithates  in  the  urine.  These  attacks  of  vertigo  may  be 
violent,  and  repeated  often,  perhaps  twice  or  more  in  the  twenty-four 
hours.  Confusion  of  mind  and  failure  of  memory  are  apt  to  co-. 
exist  with  the  vertigo.  Also  shooting  pains  in  the  limbs  and  joints. 
In  this  vertigo  of  lithaemia,  "  objects  seem  to  whirl  around  the  suf- 
ferer." The  special  senses,  when  the  vertigo  is  frequently  repeated, 
also  suffer,  and  there  is  apt  to  be  much  neuralgia,  affecting  the  bra- 
chial, intercostal,  and  sciatic  nerves;  and  also  gastralgia,  sleeplessness, 
languor  and  lassitude,  depression  of  spirits,  and  great  irritability  of 
temper  characterizes  these  cases. 

To  cure  this  form  of  vertigo,  we  must  cure  the  lithaemia,  which  is 
the  cause  of  it,  by  a  strict  diet,  eliminating  all  but  the  white  meats 
and  poultry,  making  the  patient  rest  from  work,  exercise  freely  in 
the  open  air;  use  alkaline  purgative  waters — Poland  water,  which 
neutralizes  the  uric  acid  by  its  alkalinity,  and  acts  freely  as  a  diuretic, 
as  does  also  the  Saratoga  Vichy — and  citrate  of  lithia  as  a  medi- 
cine, with  a  course  of  small  doses  of  arsenic.  If  such  patients  are 
sent  where  they  can  live  in  clear  bracing  mountain  air  for  a  few 
months,  taking  exercise,  they  will  make  a  good  recovery  and  the 
vertigo  will  disappear. 

Vertigo  may  be  associated  with  brain  disease,  and  the  movements 
may  be  gyratory,  or  a  falling  backward  or  forward.  Vertigo  accom- 
panies nearly  all  of  the  organic  lesions  of  the  brain,  and  nearly  all 
of  the  acute  inflammatory  affections  of  it.  In  the  treatment  of  ver- 
tigo from  overwork  and  anxiety,  rest,  and  freedom  from  all  care  and 
work  is  an  essential  part  of  our  treatment.  If  oxaluria  is  suspected, 
as  I  have  said,  the  administration  of  fifteen  drops  of  the  dilute  nitro- 
muriatic  acid  before  each  meal  will  generally  effectually  remove  it, 
and  the  bromide  of  ammonium  may  be  advantageously  administered. 
The  treatment  of  vertigo,  complicated  with  brain  troubles,  must  be 
guided  by  the  particular  group  of  symptoms  which  present  them- 
selves in  any  given  case.  The  application  of  the  galvanic  current 
of  electricity  in  all  forms  of  vertigo  will  be  found  to  be  of  great 
service  as  central  galvanization,  or  by  the  application  of  both  poles 
on  each  side  of  the  sixth  and  seventh  cervical  vertebrae,  using  from 
twelve  to  twenty  cells,  as  the  case  may  be. 

30 


466  PSYCHOLOGICAL    MEDICINE. 

CHAPTER  XXV. 

STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,    ETC. 

There  is  great  interest  and  importance  attaching  to  this  subject, 
but  we  are  accustomed  to  very  vague  and  undefined  ideas  respecting 
it.  My  effort  in  this  chapter,  aside  from  treating  of  the  diseases  of 
somnambuhsm  and  catalepsy,  will  be  to  contribute,  in  however  slight 
a  degree,  to  the  knowledge  of  the  more  exact  relations  of  the  human 
mind  and  of  human  acts  to  responsibility. 

We  have  been  accustomed  to  regard  the  partial  interference  with 
sensibility  and  mobility,  and  the  resulting  limitation  of  will  in  trance, 
trance-coma,  somnambulism,  catalepsy,  and  epilepsy,  as  curious 
physiological  states  rather  than  as  diseased  states  of  the  nervous 
system  requiring  medical  treatment,  and  also  seriously  affecting 
mental  and  legal  responsibility.  It  is  only  in  the  most  perfectly- 
balanced  minds,  where  there  is  an  accurate  balance  between  the  sub- 
jective and  the  objective  faculties,  that  consciousness  is  never  im- 
paired, and  where  there  are  no  breaks  in  the  continuity  of  perception 
and  memory,  during  which  time  the  connection  of  the  individual 
with  the  thing  done  or  said  is  no  longer  reliable  or  distinct.  Even 
in  men  of  the  strongest  mental  calibre  such  obliviousness  sometimes 
occurs.  In  whatever  these  intercurrent  spaces  of  non-existence  may 
have  originated,  whether  from  unfettered  determination,  or  the  idle 
Avandering  imagination,  or  from  the  brain-wasting  following  moral 
or  intellectual  hard  work,  it  is  certain  that  occasionally  they  pass  be- 
yond the  power  and  in  defiance  of  the  will,  and  should  be  classed 
under  the  head  of  morbid  nervous  affections,  if  not  with  actual  men- 
tal disorder.*  Men  of  lofty  intellect  and  vigorous  and  acute  minds, 
by  excessive  and  continuous  application,  overtaxing  their  attention 
and  introspection,  and  confining  the  exercise  of  their  intellect  and 
memory  within  a  narrow  range,  weaken  their  observant  powers,  and 
by  concentrating  their  minds  upon  particular  objects,  produce,  often- 
times, grave  disorders  of  the  nervous  system.  Sir  Joshua  Reynolds 
and  Sir  Isaac  Newton  are  prominent  examples  of  attention  so  long 
fixed  and  contemplation  so  intense  as  to  render  them  entirely  oblivi- 
ous  to    self  and   surroundings    and   to   disturbances   in   perception. 

*  This  was  clearly  laid  down  in  the  London  Journal  of  Psychological  Medicine  by 
Dr.  Forbes  Winslow  some  years  ago. 


STATES    OF    UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY,  ETC.      467 

After  Sir  Joshua  Reynolds  had  been  for  hours  occupied  in  painting 
and  walked  out  into  the  street,  the  lamp-posts  seemed  to  him  to  be 
trees,  and  the  men  and  women  moving  shrubs.  He  had  fixed  his 
attention  for  such  a  length  of  time  on  the  picture  before  him  that  he 
could  not  direct  it  to  other  objects  of  sensation. 

A  very  remarkable  instance  of  forgetfulness  and  absence  of  mind 
occurs  in  the  biography  of  Hookham  Frere,  the  scholar  and  man  of 
letters,  who,  handing  the  Countess  of  Errol  to  supper,  drank  the 
negus  he  had  prepared  for  her,  and  altogether  forgot  the  object  of 
their  visit  to  the  dining-room ;  and  who,  on  the  day  of  his  marriage 
with  the  same  lady,  had  no  recollection,  until  the  evening,  that  he 
had  promised  to  accompanj^  his  bride  to  the  country,  having  occu- 
pied the  intervening  time  in  reading  his  poem  to  his  publishers.  It 
is  a  psychological  fact,  that  after  the  attention  has  been  for  a  great 
while  intensely  fixed  upon  particular  objects,  the  person  cannot  di- 
rect it  at  will  to  other  objects  of  sensation.  Any  occupation  or  ex- 
ercise which  narrows  the  scope  of  intellectual  exercise,  which  nulli- 
fies the  influence  of  the  emotions  or  contracts  the  mental  forces,  is 
directly  prejudicial  to  mental  health,  by  giving  undue  prominence  to 
certain  faculties  and  allowing  others  to  fall  into  disuse  and  apathy, 
overstimulating  some  regions  of  the  brain  and  probably  producing 
undue  or  defective  nutrition  in  certain  parts  of  the  brain.  It  is  the 
peculiarity  of  all  these  states,  when  they  are  not  merely  temporary 
effects  of  overwork,  that  they  essentially  consist  in  such  consequen- 
ces of  bodily  or  mental  degeneration  as,  robbing  the  thinking  part 
of  our  nature  of  its  nobler  endowments,  leave  it  in  the  impoverish- 
ment of  an  appetite,  a  peculiarity,  or  a  single  all-embracing  thought. 
The  morbid  element  consists  chiefly  in  fixedness — in  the  inability  of 
the  will  to  substitute  another  train  of  reflection  or  perception.  The 
will,  though  feeble  and  fickle,  is  not  entirely  extinct,  as  it  serves  to 
guide  in  the  direction  of  the  predominating,  if  not  constantly  per- 
manent, notion  or  incentive.  It  seems  to  me  that  we  must  class  such 
states  in  the  same  category  as  the  preoccupation  of  the  insane,  whose 
disordered  imaginations  can  admit  of  nothing  but  the  present  ruling 
impulse,  and  with  the  absorbing  and  exclusive  anguish  of  the  melan- 
choliac.  In  all  these  cases  there  exists,  in  different  degrees,  a  sus- 
pension of  consciousness.  These  spaces  of  non-existence  are  on 
the  border  line  which  divides  sanity  from  insanity.  The  morbid 
states  of  the  brain  which  may  be  induced  are  exemplified  in  a 
marked  degree  in  the  lives  of  ascetics  and  ecstatics,  and  in  those 


468  PSYCHOLOGICAL    MEDICINE. 

whose  intense  devotional  feelings,  as  in  the  convulsionaries  and 
Brahmins,  extend,  for  the  time,  to  enfeeblement  of  volition  and  to 
diseased  functions  of  motivity  and  sensibility,  manifested  in  violent 
convulsions  and  complete  loss  of  sensation. 

In  somnambulism,  the  first  of  the  morbid  states  which  I  propose  to 
consider,  we  have,  as  the  constant  and  unvarying  state,  a  morbidly 
profound  sleep,  in  which  "  the  sceptre  of  reason  is  surrendered  to  a 
physically  directed  fancy."  It  is  due,  probably,  either  to  an  over- 
loaded stomach  pressing  on  the  solar  plexus  of  nerves,  producing  a 
partial  paralysis  in  the  coats  of  the  arteries,  and  so  in  the  circulation  of 
the  brain ;  sleeping  with  the  head  too  low,  and  strong  mental  emotion. 
It  is  a  peculiarity  of  somnambulism  that  even  after  the  removal  of 
the  cause,  the  habit,  once  established,  is  apt  to  remain.  It  is  most 
frequent  in  youth,  and  about  the  age  of  puberty.  In  the  states  of 
unconsciousness  accompanying  somnambulism,  the  senses  are  awake 
and  preternaturally  alive.  The  muscles  are  regulated,  and  regulated, 
too,  with  wonderful  precision  and  power.  There  is  a  purpose,  and 
there  is  a  coordination  of  acts  for  its  accomplishment ;  but  conscious- 
ness is  still  asleep,  and  memory  retains  no  record  of  the  transaction, 
although  it  may  have  been  prejudicial  in  the  highest  degree  to  the 
interest  of  the  actor  or  of  others.  In  many  states  of  unconscious- 
ness the  mind  is  forced  to  think  or  feel  in  a  particular  way,  and  is 
forced  to  instigate  certain  deeds  in  flagrant  opposition  to  its  ordi- 
nary character  and  tendencies,  and  in  utter  disregard  of  the  prompt- 
ings, or  of  the  resistance  of  other  motives  and  considerations.  There 
is  a  very  close  relation  between  acts  committed  during  states  of  un- 
consciousness and  mania  transitoria,  epileptic  paroxysms,  and  the  ir- 
resistible impulses  of  insanity.  They  have,  in  common,  irresisti- 
bility, suddenness  and  rapidity.  They  are  alike  unannounced  and 
of  short  duration.  They  are  alike  characterized  by  the  exercise  of 
free-will  being  fettered  or  perverted,  and  there  are,  undoubtedly,  dis- 
tinct morbid  conditions  in  all  of  these  different  states.  If  we  exam- 
ined with  sufficient  care,  cases  in  which  unconsciousness  occur,  I  feel 
quite  sure  we  should  discover  the  prodromic  signs  which  have  been 
observed  to  usher  in  other  species  of  the  neuroses.  Somnambulism 
may  be  hereditary,  but  it  is  not  inconsistent  with  fair  health.  It  is 
apt  to  become  periodical,  patients  having  attacks  once  a  week,  fort- 
night or  month. 

The  treatment  of  somnambulism  consists  in  preventing   the  very 
deep  sleep,  in  which  the  phenomena  of  somnambulism  are  exhibited. 


STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM CATALEPSY,  ETC.      469 

The  patient  should  be  awakened  one  or  twice  a  night  before  the 
phenomena  begin  to  appear ;  soon  after  retiring  and  again  after 
four  or  five  hours  sleep,  will  usually  answer.  Patients  should  dine 
in  the  middle  of  the  day,  and  while  taking  care  that  all  meals  should 
be  light  and  digestible,  we  should  be  particularly  careful  not  to  over- 
load the  stomach  at  night.  The  use  of  electricity  and  nerve  tonics 
to  bring  up  the  general  health  to  the  highest  point  are  indicated. 
Friends  should  be  cautioned  not  to  awaken  the  patient  while  walk- 
ing, as  the  fright  may  act  prejudicially.  He  should  be  quietly  put 
back  to  bed.  The  head  should  be  well  propped  up  by  pillows,  and 
too   great  a  weight  of  clothes  must  be  avoided. 

Catalepsy. — I  find  an  excellent  definition  of  catalepsy  in  Dr.  Boer- 
haave's  aphorisms,  published  in  1755.  He  graphically  describes  it 
as  "that  disease  in  which  the  patient  becomes  of  a  sudden  unmoved, 
void  of  feeling,  and  retains  the  same  posture  and  action  of  all  the  parts 
of  his  body  which  it  was  in  when  the  disease  seized  him  first."  It  is  a 
disease  of  central  innervation  of  the  nervous  system,  and  may  be  ac- 
companied by  or  accompany  many  forms  of  insanity.  In  a  cataleptic 
paroxysm,  the  state  of  unconsciousness  is  characterized  by  the  limbs 
of  a  patient  remaining  in  the  position  in  which  the  patient  had  placed 
them  before  the  inception  of  the  paroxysm,  or  in  which  any  by- 
stander may  place  them  during  the  paroxysm.  Consciousness  and 
sensibility  are  entirely  suspended.  Catalepsy  may  accompany  in- 
sanity and  chorea,  and  many  of  the  neuroses.  If  death  is  simulated, 
the  existence  of  muscular  contractility  under  the  Faradic  current, 
and  also  the  dark  eschar  of  the  cautery,  are  tests  which  may  be  ap- 
plied to  determine  life.  The  patient's  will  is  powerless  to  act  dur- 
ing the  paroxysm,  by  reason  of  the  muscular  contraction  induced  by 
excitement  of  the  motor  nerves,  proceeding  from  the  spinal  cord. 
The  paroxysm  is  preceded  by  dizziness,  headache  and  a  very  irrita- 
ble state  of  the  general  nervous  system,  and  begins  very  suddenly. 

There  is  apt  to  be  a  vague  uneasiness  and  sleeplessness.  A  pa- 
tient of  mine  presented  the  following  typical  symptoms  and  manifes- 
tations of  a  cataleptic  attack  in  my  presence.  The  lady  in  question, 
who  was  from  North  Carolina,  while  in  the  act  of  conveying  a  morsel 
of  food  to  her  mouth,  became  suddenly  rigid  and  pale,  the  arm  being 
arrested  in  its  passage  and  being  immovably  fixed,  with  the  fork  in 
the  hand  a  few  inches  from  the  mouth.  The  whole  body  was  as  mo- 
tionless as  if  the  patient  were  carved  out  of  stone.  The  eyes  pre- 
sented a  widely  opened,  staring  condition,  and  consciousness  and 


470  PSYCHOLOGICAL    MEDICINE. 

sensibility  were  entirely  suspended.  Respiration  could  not  be  de- 
tected and  the  pulse-wave  could  not  be  felt  at  all.  In  about  four 
minutes  the  patient  sighed  deeply,  made  a  full  inspiration,  and  re- 
sumed her  meal,  quite  unaware  of  what  had  happened  to  her.  The 
cataleptic  trance  may  last  for  some  hours  possibly,  and  in  extreme 
cases  may  last  for  days.  Patients  remember  nothing  of  an  attack  or 
what  transpires  during  the  trance-like  state. 

Catalepsy,  although  not  necessarily  connected  with  insanity,  is,  I 
think,  very  often  dependent  upon  an  insane  temperament  or  neurosis. 
It  has  been  stated  that  catalepsy  is  generally  a  complication  of  hys- 
teria, but  the  results  of  one  hundred  and  forty-eight  cases  collected 
by  Dr.  Fuel,  in  which  sixty-eight  occurred  in  males,  would  seem  to 
disprove  the  assertion.  An  interesting  case  of  this  rare  disease  was 
reported  by  Dr.  S.  S.  Cornell,  of  Toledo,  Ont.,  not  long  ago.  The 
catalepsy  came  on  after  the  second  confinement,  before  which  the 
patient  was  very  nervous.  After  the  confinement  there  was  a  chill 
followed  by  sharp  febrile  action,  with  pain  and  tenderness  over  the  re- 
gion of  the  uterus.  There  was  some  delirium  and  suppression  of  lo- 
chia. This  condition,  however,  disappeared,  but  was  followed  by  a 
cataleptic,  state,  which  I  give  in  the  Dr.'s  own  language :  "  Now  comes 
the  sequel.  The  patient  passed  the  next  forty-eight  hours  most 
beautifully,  except  on  the  night  of  the  30th  she  could  not  sleep  ; 
otherwise  the  nurse  thought  she  was  doing  extremely  well.  A  pecu- 
liar change  was  soon  discovered  taking  place  with  the  patient ;  her 
acuteness  of  hearing  was  extremely  great ;  could  hear  and  reiterate 
the  sentiments  of  persons  in  the  adjoining  room,  who  conversed,  as 
they  declared  to  me,  in  a  low  whisper,  and  that  they  conceived  it 
impossible  for  a  person  to  hear  a  word  whispered  six  feet  from  them  ; 
yet  this  patient  at  a  distance  of  twenty  feet  or  more,  with  closed  doors, 
could  tell  the  sentiments  exchanged.  This  was  done  several  times, 
and  finally  the  patient  called  her  husband  to  her,  kissed  him  ;  then 
called  her  little  boy  three  years  old,  and  her  infant,  kissed  them  and 
then  bade  her  friends  adieu.  This  procedure  of  my  patient  awoke 
a  deep  interest  in  the  minds  of  the  nurse  and  friends,  who  now  be- 
came alarmed.  The  nurse  persuaded  the  friends  to  leave  the  room 
to  her  and  the  patient,  as  she  thought  after  a  little,  Mrs.  H.  would 
fall  into  a  repose ;  but  instead  of  sleep,  our  patient  lay  speechless  and 
motionless,  with  eyes  staring  wide  open,  no  signs  of  respiration ; 
they  opened  her  mouth  to  see  if  she  would  swallow,  but  in  vain  ; 
her  lower  jaw  remained  depressed  as  the  nurse  had  left  it.    Attempts 


STATES    OF   UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      4/1 

were  now  made  to  rouse  her  by  calling  loudly  in  her  ear,  but  to 
which  she  paid  no  attention.  They  thought  her  dead,  and  that  it 
was  useless  to  send  for  medical  aid ;  thus  passed  away  twelve  hours, 
when  her  husband  dispatched  a  messenger  for  me.  When  I  arrived 
and  entered  the  room,  I  was  shocked  to  see  what  struck  my  fancy 
to  be  a  waxen  figure  or  a  frozen  corpse  in  lieu  of  my  former  patient. 
There  she  lay  with  under  jaw  depressed,  eyes  staring  and  wide  open, 
without  winking,  the  pupils  a  little  dilated,  skin  cool,  almost  the  feel 
of  a  corpse  before  stiffening,  pulse  122,  feeble,  no  sign  of  respiration. 
In  examining  the  pulse  I  raised  the  arm  to  see  if  that  would  cause 
any  difference  in  the  pulse.  There  it  remained  for  nearly  an  hour, 
when  I  put  it  down  by  her  side.  There  was  but  little  resistance 
offered  to  any  change  of  her  limbs  or  person ;  but  whatever  attitude 
a  limb  was  placed  in,  there  it  remained.  I  now  brought  her  under 
jaw  up  to  its  place  and  it  remained.  I  was  importuned  to  do 
something  for  the  patient.  What  to  do  was  with  me  a  paramount 
question.  The  thought  occurred  to  me  that  I  might  administer  an 
enema  of  strong  solution  of  assafoetida,  which  I  did  to  the  amount  of 
a  quart ;  and  this  was  very  easily  done  as  there  was  not  the  slightest 
resistance.  Still  the  patient  lay  as  lifeless  as  ever  for  about  an  hour, 
when  a  few  slight  convulsive  movements  were  observed,  and  she 
roused  to  consciousness.  She  looked  about  her,  asked  what  had  been 
done  with  her  corpse,  as  it  appeared  to  her  that  her  friends  desired 
her  to  remain  for  a  season,  but  her  judgment  dictated  to  her  to  again 
depart  and  take  her  infant  with  her.  I  gave  her  several  doses  of 
assafoetida,  fluid  extract  of  valerian,  beef  tea,  etc.  She  now  desired 
to  be  left  alone,  as  she  said  she  had  an  important  duty  to  perform, 
and  the  presence  of  persons,  however  nearly  related,  was  detrimen- 
tal to  her  welfare.  She  was  satisfied  for  me  to  remain  with  her  alone, 
as  she  said,  "  from  the  days  of  antiquity,  deference  had  always  been 
paid  first  to  the  priest  and  then  to  the  doctor."  She  remained  quiet 
for,  in  all,  a  period  of  six  hours,  taking  beef  tea,  valerianate  of  am- 
monia, assafoetida  and  bromide  of  potassium.  Soon  she  drew  the 
sheet  over  her  face,  and  then  placed  her  arms  over  her  chest  and  lay 
straight  in  bed ;  she  lay  so  quiet  and  still  that  I  felt  induced  to  re- 
move the  sheet,  when,  as  I  had  feared,  I  found  her  in  a  second  trance  (?). 
Eyes  wide  open,  pupils  a  little  dilated,  but  would  contract  under  the 
influence  of  strong  light ;  skin  cold,  of  a  death-like  feel,  no  rigidity 
of  the  muscles;  pulse  112  and  very  feeble;  not  the  first  sign  of  res- 
piration, no  movements  of  the  nostrils,     I  now  lifted  her  body  up  to 


4/2  PSYCHOLOGICAL   MEDICINE. 

an  obtuse  angle  with  her  lower  limbs,  I  next  raised  one  armandthen 
the  other,  and  in  this  position  I  left  her  for  several  minutes.  I  now 
stepped  back,  gazed  upon  my  patient,  who,  in  a  semi-sitting  posture, 
with  staring  eyes,  with  outstretched  arms  and  a  lifeless  appearance, 
appeared  as  though  a  corpse  had  thus  been  placed  and  left  to  stiffen. 

I  then  laid  her  down  upon  the  pillow,  raised  her  body  up,  having 
her  head  on  the  pillow  in  the  attitude  of  opisthotonos,  and  thus  she 
remained;  after  a  period  of  twenty  minutes,  I  gave  her  a  slight  push 
and  she  fell  on  her  left  side  with  her  body  still  having  the  same 
curve,  I  now  straightened  her  out  in  bed,  spoke  loudly  to  her  several 
times,  but  no  response.  I  again  repeated  the  assafoetida  injection, 
containing  ol.  terebinthinae.  To  please  her  friends,  I  tried  several 
times  to  have  her  swallow,  but  all  to  no  purpose.  I  held  to  her  nose 
strong  aqua  ammonia,  which  affected  her  in  no  perceptible  way. 
In  this  state  she  lay  about  eight  hours ;  when  consciousness  re- 
turned she  related  what  she  saw  while  in  the  other  world.  This 
time  she  was  not  so  composed  and  tranquil  as  when  she  came  out  of 
the  first  trance  (?).  Her  symptoms  now  assumed  more  the  character  of 
h\'Steria,  her  limbs  were  affected  with  convulsive  twitchings,  and  she 
screamed  loudly  without  giving  utterance  to  any  cause  for  so  doing. 
When  she  went  into  the  second  state  of  mental  abeyance,  my  views 
were,  as  soon  as  consciousness  returned,  that  she  should  be  brought 
under  some  powerful  anaesthetic,  whereby  her  mental  state  might 
recuperate.  Whether  this  should  be  produced  by  chloroform,  ether 
or  hydrate  of  chloral  v.-as  not  fully  settled  in  my  mind.  I  therefore 
sent  for  Dr.  Addison  of  Farmersville,  who  arrived  just  after  her  im- 
perfect return  to  consciousness.  It  was  decided  at  once  to  give  her 
hydrate  of  chloral,  of  which  she  took  seventy  grains  in  the  space  of 
an  hour,  after  which  she  fell  into  a  profound  sleep  and  did  not  awaken 
for  twelve  hours.     Her  convalescence  then  commenced." 

These  cases  are  of  interest  to  the  practitioner,  although  compara- 
tively rare,  as  the  cataleptic  paroxysm  or  fit  annoys  or  disturbs  the 
patient's  mind,  lest  they  should  come  on  while  travelling  or  away 
from  home  and  friends.  Although  the  fits  generally  last  but  a  few 
minutes  they  may  possibly  last  for  several  hours  or  even  days.  The 
chief  indication  for  treatment  are  to  improve  the  general  nervous 
tone  by  nerve  tonics  and  electricity ;  induce  the  patient  to  lead  an 
outdoor  life,  eat  regularly,  avoid  rich  indigestible  food ;  to  retire 
early ;  and  if  the  patient  complain  of  a  sleepless  condition  to  admin- 
ister the  ammoniated  tincture  of  lupulin,  made  by  William  Neergaard, 


STATES    OF    UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY,  ETC.      4/3 

the  chemist  of  this  city,  in  twenty-minim  to  one-drachm  doses,  or 
Fothergil's  solution  of  hydrobromic  acid  in  thirty-drop  doses,  in 
water,  at  bed-time.  I  have  found  the  constant  current  of  electricity 
useful  in  the  form  of  centric  galvanization.  To  recapitulate :  Cata- 
lepsy comes  on  suddenly,  generally  after  mental  or  emotional  dis- 
turbances ;  the  body  becomes  corpse-like  and  pale,  the  respiration 
being  slow,  and  the  pulse  very  soft  and,  perhaps,  not  discernible. 
The  patient  cannot  be  roused,  and  sensibility  is  lost.  The  stiffness 
of  the  muscles  is  a  diagnostic  feature  of  the  disease,  which  is  such 
that  if  a  limb  be  put  forcibly  into  any  position  it  retains  it.  Patients 
remember  nothing  of  any  attack  or  what  transpires  during  its  con- 
tinuance. 

In  all  states  of  unconsciousness,  where  there  is  disseverment  of  the 
will  from  the  organs  habitually  acted  on  by  it,  and  during  which 
odd,  eccentric  or  dangerous  acts  are  committed,  it  would  seem  most 
probable  that  while  memory  is  annihilated,  the  acts  are  the  outcome 
of  the  sensations,  ideas,  emotions,  acts  and  events  of  antecedent  life, 
and  not  inventions  new  to  the  senses.  I  doubt  if  the  mind  ever  ac- 
tually ceases  in  its  operations  or  workings ;  and  it  is  probable  that 
actions  analogous  in  kind  although  variously  altered  in  operation, 
occur  in  the  brain,  alike  in  unconscious  and  conscious  states,  in  much 
the  same  manner  as  they  occur  in  the  sleeping  and  in  the  waking  brain. 
It  is  a  very  difficult  matter  to  try  to  define  or  explain  mental  action 
in  these  states,  because  there  are  as  many  forms  and  degrees  of  dis- 
ordered mental  action  in  states  of  unconsciousness  as  of  the  intellec- 
tual and  moral  qualities  in  their  sane  state.  The  confused  and  per- 
verted notions  of  right  and  wrong  in  opium  habitues,  where  the 
opium  dulls  and  deadens  the  moral  sense  without  seeming  to  dis- 
turb the  intellectual  faculties — owing  to  the  close  relation  between 
opium  and  consciousness — have  a  very  interesting  medico-legal 
bearing,  as  these  cases  inhabit,  more  or  less  of  the  time,  a  realm  of 
partial  unconsciousness ;  but  this  subject  is  too  complex  to  admit  of 
further  mention  in  this  paper. 

The  instigation  to  give  way  to  inexplicable  and  ungovernable  im- 
pulse, to  cry  out  or  shriek,  to  perpetrate  a  homicide  or  suicide,  or  to 
commit  some  motiveless  act  of  violence  or  otherwise,  and  some  of 
the  acts  of  kleptomaniacs,  come  under  the  head  of  states  of  uncon- 
sciousness.*    In  families  where  madness  is  hereditary,  there  would 

*  At  the  time  of  writing  this  a  patient,  15  years  of  age,  tells  us  that  she  should  feel 
"  so  much  better  if  she  could  only  kill  somebody."  Who,  she  cares  not.  There  is  a 
strong  impulse  to  commit  the  act. 


474  PSYCHOLOGICAL    MEDICINE. 

seem  to  be  a  similarity  or  identity  of  the  inner  nature  of  different 
members  of  the  same  family,  which  would  appear  to  incite  them  to 
the  act  of  self-destruction  without  any  appreciable  incentive  to  the 
act.  The  suicidal  act  or  deed  in  such  instances  is  probably  com- 
mitted during  a  temporary  partial  state  of  unconsciousness. 

In  the  case  of  the  young  English  lady  of  wealth  and  refinement 
who,  while  expensively  dressed,  took  a  greasy  piece  of  meat  from  a 
butcher's  shop,  placing  it  between  her  velvet  jacket  and  her  silk  dress, 
and  walked  off  with  it — is  it  rational  to  suppose  that  she  was  con- 
scious of  what  she  was  doing  ?  There  is  certainly  a  modified  state 
of  consciousness  in  kleptomania  which  makes  the  victim  of  this  un- 
happy disease  but  very  imperfectly  conscious  of  the  nature  of  the  act. 
When  this  morbid  propensity  appears,  it  generally  comes  on  sud- 
denly, and  is,  I  think,  owing  to  some  peculiar  change  in  the  nervous 
constitution  of  the  woman — for  it  is  generally  women  who  are  af- 
fected with  this  type  of  nervous  disorder.  An  uncontrollable  im- 
pulse seems  to  usurp  the  whole  mind  for  the  time  being,  and  efface 
all  other  impressions.  It  seems  to  annihilate  personality  by  exclud- 
ing all  the  relations  which  determine  it.  I  have  in  my  own  mind, 
determined  the  invasion  of  insanity  in  patients  who  acknowledged 
such  instigations  as  I  have  spoken  of,  to  homicide  or  suicide,  which 
they  had  not  given  way  to,  but  which  had  excited  their  amuse- 
ment rather  than  their  appreciation,  as  in  a  sound  mind  would  be  the 
result.  A  patient  of  mine,  who  appreciated  his  own  condition,  con- 
fessed to  me  that  he  dreaded  to  look  at  children,  because,  although 
he  was  very  fond  of  them,  he  felt  irresistibly  impelled  to  kill  them. 
He  related  to  me  a  struggle  in  his  own  mind  which  occurred  upon 
seeing  a  child  on  the  deck  of  a  steamer,  in  which  he  successfully  re- 
sisted the  impulse  to  throw  the  child  overboard.  He  said  that  he 
experienced  a  dreadful  mental  contest,  and  that  his  head  swam  and 
everything  looked  black  before  his  eyes.  He  knew  perfectly  well 
that  it  would  be  wrong  to  commit  such  an  act,  but  his  will- 
power was  very  nearly  overthrown  by  the  disease.  A  lady,  who 
was  under  my  care,  was  irresistibly  impelled  to  suddenly  shriek 
aloud  at  any  moment,  and  struggles  hard  against  these  impulses. 
She  is  accustomed  to  have  momentary  periods  of  insensibility — 
caused,  I  think,  by  anaemia  of  the  brain — in  which  she  steadies  her- 
self by  a  table  or  chair,  and  generally  manages  to  avoid  the  obser- 
vation of  those  in  the  room.  This  lady,  although  sane  in  the  eyes 
of  the  world,  has  twice  attempted  suicide,  and  in  common  with  other 
insane  acts  these  attempts  have  never  caused  her  a  moments'  regret, 


STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      475 

although  I  have  repeatedly  endeavored  to  elicit  such  an  expression 
from  her.  There  is  a  taint  of  mental  disorder  in  the  family.  An- 
other lady  lately  came  to  this  city  from  Massachusetts  to  consult  me 
about  an  irresistible  impulse  to  throw  herself  from  any  horse  car,  steam 
car,  steamboat  or  moving  vehicle  she  was  in.  She  deeply  deplored 
this  impulse,  but  it  completely  overpowered  her,  and  she  lived  in 
fear  that  she  should  give  way  to  the  impulse.  She  had  a  lady  friend 
accompany  her  constantly.  In  this  case  the  cause  was  evidently 
dependent  upon  anaemia  of  the  brain  and  spinal  cord.  An  appropriate 
course  of  treatment  cured  her.  There  was  not  the  element  of  in- 
sanity in  her  case.  She  complained,  however,  of  lack  of  complete 
consciousness  at  such  times,  which  fact  she  appreciated,  and,  there- 
fore, never  trusted  herself  alone.  I  desire  to  call  especial  attention 
to  the  fact  that  there  are,  preceding  many  states  of  unconsciousness, 
premonitory  conditions  of  sadness,  peevishness,  irritability,  quarrel- 
someness, torpidity  of  conception,  failure  of  memory,  obtuseness  of 
ideas,  hebetude  and  prostration,  followed,  as  the  climax  appears,  by 
excessive  gayety,  excessive  exaggeration  of  physical  strength,  rest- 
lessness, vertigo,  and  passionate  outbursts  of  fury.  There  are  also 
in  these  states  headache,  vomiting,  and  neuralgia. 

These  constitutional  states  of  morbid  action  show  us  that  it  would 
be  very  difficult  for  the  mind  to  act  calmly  or  clearly,  and  they  also 
show  a  predisposition  to  actual  mental  disorder.  These  premoni- 
tory symptoms  should  always  be  inquired  after  in  medico-legal  in- 
vestigations, as  they  are  really  a  part  of  the  diseased  state  of  the 
nervous  system,  and  often  precede  the  outward  explosion  for  months. 
They  constitute  a  part  of  the  disease  in  the  same  way  that  the  pre- 
monitory aura  constitutes  an  integral  part  of  the  epileptic  fit,  when 
it  is  present. 

I  think  more  importance  should  be  attached  to  the  subject  of  un- 
controllable impulse,  and  the  legal  profession  should  believe  in  its 
existence.  At  present,  acts  of  unconquerable  and  destructive  im- 
pulse occurring  in  persons  whose  sanity  has  never  been  disputed,  are 
generally  visited  by  the  extreme  penalty  of  the  law.  These  per- 
sons, however,  I  think,  suffer  from  a  condition  not  unlike  the  first 
stage  of  epilepsy  when  pallor  of  the  face  occurs.  In  these  cases  of 
uncontrollable  impulse,  there  is  a  condition  of  vascular  tonus  causing 
pallor  of  the  face  before  the  act,  and  the  impulse  ceases  upon  the 
commission  of  the  act.  I  contend  that  in  many  of  these  cases  there 
is  disease  of  the  brain,  and  that  many  of  these  persons  are  morally 
irresponsible,  especially  as  it  has  been  shown  that  these  impulses  are 


476  PSYCHOLOGICAL    MEDICINE. 

recurrent.  The  uncontrollable  impulse  is  unlike  epilepsy  in  that 
there  is  no  complete  and  sudden  loss  of  consciousness,  while  it  re- 
sembles it  in  the  recovery' being  rapid,  and  in  the  fact  of  the  patient 
having  no  remembrance  of  the  attack  in  many  cases.  These  pa- 
tients will  tell  you  that  they  feel  an  ungovernable  impulse  to  "  do 
something."  If  the  "  doing  something  "  consisted  of  undressing  and 
shrieking  from  the  top  of  the  house,  you  would  all  say,  "  poor  crea- 
ture !  she  is  insane ;"  while,  on  the  contrary,  if  the  same  person 
seized  a  knife  and  committed  a  murder,  the  people  would  assuredly 
hang  her,  although  the  deed  would  be  equally  that  of  a  temporarily 
insane  woman,  committed  during  a  state  of  partial  unconsciousness — 
for  I  hold  that  these  individuals  are  only  very  imperfectly  conscious 
of  their  deeds.  I  consider  these  attacks  as  closely  analogous  to 
incomplete  and  abortive  epileptiform  attacks,  and  this  should  be 
accepted,  I  think,  as  their  medico-legal  significance.  In  these  in- 
complete epileptiform  attacks  there  are  no  convulsions  and  no  com- 
plete loss  of  consciousness,  the  period  being  a  mental  blank  to  the 
patient,  or  a  gust  of  passion,  or  a  slight  incoherence,  or  slight  vertigo 
perhaps.  I  think  that  there  is  a  functional  brain  disturbance  in  these 
cases  of  uncontrollable  impulse,  consisting  of  disturbance  of  the 
vaso- motor  nerves,  which  are  distributed  to  the  bloodvessels  of  the 
brain  and  form  their  calibre,  the  disturbance  consisting  of  a  condition 
of  spasm  of  the  bloodvessels  and  temporary  anaemia  of  the  brain, 
evinced  by  the  pallor  of  the  face,  which,  as  I  have  said,  accompanies 
the  uncontrollable  impulse  and  generally  characterizes  it. 

The  difference  between  the  epileptic  state  and  that  of  the  brain  in 
uncontrollable  impulse  is,  that  in  the  latter  case  the  state  of  anaemia 
is  not  followed  by  the  congestion  and  hyperemia,  which  in  epilepsy 
immediately  follows,  as  a  rule,  the  state  of  anaemia.  The  motor  tract 
of  the  brain  and  spinal  cord  is  probably  not  affected  as  in  epilepsy. 
If  this  uncontrollable  impulse  led  to  suicide,  would  you  not  consider 
it  as  the  deed  of  a  person  who  temporarily  was  of  unsound  mind? 
If  so,  should  not  the  impulse  leading  to  murder  deserve  any  amenity 
and  leniency  in  treatment?  I  think  that  uncontrollable  impulse,  in 
common  with  epilepsy,  insanity,  chorea,  etc.,  has  a  common  origin, 
that  origin  being  constitutional  disease,  or  hereditary  disease,  which 
has  been  transmitted  from  some  member  of  the  family,  more  or  less 
remote,  to  the  patient  under  obser\'ation.  It  is  a  medico-legal  point 
of  great  importance  which  should  be  borne  in  mind,  that  there  is  a 
correlation  of  morbific  forces — first  thoroughly  demonstrated  bv  Dr. 


STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      4// 

J.  M.  Winn,  of  London,  England — which  applies  to  a  large  class 
of  hereditary  diseases,  making  them  mutually  convertible ;  in  other 
words,  that  there  is,  in  hereditary  disease,  a  latent  morbific  force, 
which  accumulates,  perhaps  gathering  intensity  during  the  latent 
period,  and  finally  manifesting  itself  outwardly  by  a  maniacal  attack, 
in  the  convulsive  movements  of  epilepsy,  in  consumption,  in  a  suicidal 
act,  or  in  the  giving  way  to  an  uncontrollable  impulse  to  jump  from 
a  house,  kill  a  child,  or  violently  swear  and  use  obscene  language 
when  the  general  moral  character  may  have  been  for  months  most 
unexceptional.  It  is  a  terrific  thunderstorm  of  the  mental  and  moral 
nature,  due  to  the  explosion  of  this  subtle  morbific  force,  which  may 
have  remained  latent  for  a  long  time.  The  point  which  I  desire  to 
impress  is  this:  that  if,  in  medico-legal  investigations,  the  judiciary 
in  all  such  cases  will  take  the  same  trouble  to  institute  close  inquiry 
that  an  experienced  physician  does,  they  will,  in  many  cases,  easily 
discover  the  existence  of  hereditary  disease,  which  greatly  modifies 
the  prisoner's  moral  and  legal  responsibility;  and  surely  every  pris- 
oner is  entitled  to  the  benefit  of  such  an  investigation,  if  it  is  claimed 
that  the  criminal  action  was  the  offspring  of  disease  which  was  not 
under  the  control  of  the  unhappy  sufferer.  I  hope  I  shall  so  con- 
vince my  readers  that  it  may  be  said  in  after  years,  that  the  medical 
profession  is  entitled,  to  the  credit  of  inaugurating  in  this  country 
the  reforms  so  much  needed.  I  have  been  told  once  or  twice  by 
legal  friends  that  these  were  dangerous  doctrines;  but  I  hold  that  a 
scientific  truth  is  never  a  dangerous  doctrine,  and  I  do  not  believe 
it  right  ever  to  sacrifice  a  human  life  to  a  cautious  conservatism  that 
fears  to  accept  a  truth  because  that  truth  may  be  in  opposition  to 
traditional  dogma.  I  come,  finally,  to  the  most  important  of  the 
states  of  unconsciousness,  that  connected  with  the  disease  of  epilepsy. 
Epilepsy  is  a  functional  disease  of  the  nervous  centres,  the  phe- 
nomena of  which  morbid  state  consists  in  seizures,  generally  sudden 
in  their  invasion,  and  preceded,  as  a  rule,  by  a  well-marked  pro- 
dromal period,  characterized  by  loss  of  consciousness,  coming  on 
suddenly,  and  attended  by  peculiar  involuntary  muscular  movements, 
which  are  highly  spasmodic  and  convulsive  in  nature.  There  is 
great  medico-legal  importance  attaching  to  epilepsy,  from  the  reason 
that  there  have  probably  been  more  grave  crimes  cormnitted  by  persons 
epileptically  insane  than  during  all  other  states  of  unconsciousness  put 
together  in  the  annals  of  medicijie  and  law.  I  will  go  farther,  and  say 
that  I  believe  most  of  the  revolting  and  motiveless  crimes  in  the  annals 


4/8  PSYCHOLOGICAL    MEDICINE. 

of  history  to  be  due  to  the  epileptic  state.  Revolting  and  motiveless 
crimes  often  form  substitutes  for  the  epileptic  paroxysm,  just  as 
periods  of  faintness  or  automatism  often  take  the  place  of  a  fit. 
Whether  or  not  the  tragedies,  like  the  one  I  shall  shortly  relate,  are 
ever  premeditated  in  imagination  during  the  period  of  incubation  of 
the  fits,  is,  I  think,  a  very  difficult  question  to  answer.  The  state 
of  unconsciousness  occurring  in  epilepsy  may  be  substituted  by  any 
grade  of  sudden  acts  of  fury  and  violence,  homicide  or  suicide.  A 
premonition  of  an  epileptic  fit  has  been  followed  by  a  state  of  uncon- 
sciousness, during  which,  instead  of  having  the  convulsion,  persons 
have  walked  long  distances,  in  one  instance  as  far  as  eight  miles. 
The  recollection  in  this  instance  was  a  complete  blank.  If  any  catas- 
trophe had  been  the  result  of  this  period  of  walking  coma  in  these 
cases,  during  which  time  there  was  a  total  suspension  of  present 
knowledge  and  memory,  I  am  afraid  that  the  plea  of  temporary 
unsoundness  of  reason  would  have  been  looked  upon  with  decided 
suspicion;  yet  the  series  of  psycho-physical  disturbances  in  these 
cases,  whether  apart  or  identified  with  an  epileptic  diathesis,  directly 
affects  the  soundness  of  mind.  The  most  insidious  of  these  states 
of  unconsciousness  is,  that  which  dates  from  the  close  of  the  grand 
mal,  or  fully  developed  epilepsy,  with  convulsions.  This  state  may 
continue  for  some  days  after  an  epileptic  convulsion,  and  the  patient 
appears  so  much  like  himself  as  to  deceive  even  his  friends  into  the 
belief  that  he  is  mentally  normal.  This  state  seems  to  be  compatible 
with  many  rational  actions,  and  its  existence  is  not  generally  sus- 
pected until  the  commission  of  some  crime,  like  the  poisoning  about 
to  be  spoken  of,  which  succeeded  a  nocturnal  fit  of  epilepsy.  My 
opinion  is,  as  it  will  be  seen  in  the  narration  of  this  case,  that  there 
should  be  immunity  of  punishment  to  epileptics  for  criminal  acts 
committed  within  three  days  before  or  after  an  attack,  such  act  being 
evidence  to  me  of  mental  unsoundness. 

In  conclusion,  I  will  speak  of  the  psychological  aspect  of  the  Laros 
case,  on  the  trial  of  Allen  C.  Laros,  at  Easton,  Pennsylvania,  for  the 
murder  of  his  father,  Martin  Laros,  by  poison,  the  defence  being 
based  upon  the  allegation  of  epileptic  insanity.  The  history  of  this 
very  interesting  case  was  kindly  given  me  by  my  friend  Henry  W. 
Scott,  Esq.,  of  the  Pennsylvania  bar,  to  whom  I  am  indebted  for  it. 

The  Laros  family  lived  at  Mineral  Spring,  situated  on  the  Dela- 
ware River,  in  Northampton  County,  four  miles  above  Easton,  Penn- 
sylvania.    The  little  hamlet  consists  of  a  tavern  and  the  homes  of 


STATES    OF   UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.       479 

seven  or  eight  families,  near  together,  along  the  river  road.  Martin 
Laros,  the  father  of  the  family,  was  fifty-seven  years  old,  and  his  wife 
was  fifty-one.  They  had  lived  at  Mineral  Spring  for  thirty  years. 
He  taught  school  during  the  winter  months,  worked  his  farm  in  the 
summer,  and  at  the  same  time  was  employed  as  undertaker  and 
cabinetmaker.  He  was  quiet,  unobtrusive,  and  respected  in  his 
neighborhood.  Mrs.  Laros  was  a  woman  of  domestic  habits  and  . 
lively  temperament.  They  have  had  seventeen  children,  thirteen  of 
whom  are  now  living.  Several  of  them  have  been  school-teachers. 
Some  are  living  in  the  neighborhood,  and  others  have  removed  to  a 
distance.  At  the  time  of  the  poisoning,  the  family  consisted  of  the 
father  and  mother,  Allen  (the  prisoner),  Erwin,  Alvin,  Clara,  Alice, 
and  a  very  young  grandchild.  Moses  Schug,  also  a  member  of  the 
household,  was  a  bachelor,  sixty-two  years  old.  He  assisted  Martin 
Laros  on  the  farm  and  in  the  shop. 

One  evening,  while  the  family  were  at  the  supper-table,  they  were, 
one  by  one,  taken  violently  ill.  Neighbors  came  in  to  do  what  they 
could  for  the  sick,  and  physicians  were  summoned.  Allen  also 
assisted  in  caring  for  the  sick;  he  was  taken  sick  later  in  the  evening. 
Mrs.  Laros  died  at  seven  o'clock  the  next  morning.  Mr.  Laros  also 
died  on  the  same  day,  about  noon,  and  Moses  Schug  at  three  o'clock 
on  the  following  afternoon.  The  other  members  of  the  family  re- 
covered in  about  a  week.  The  fatal  supper  was  partaken  of  on 
Wednesday.  The  coroner's  inquest  was  begun  on  Thursday  after- 
noon, and  on  Saturday  the  following  verdict  was  rendered:  "That 
the  said  Martin  Laros,  Mary  Ann  Laros,  and  Moses  Schug  came  to 
their  deaths  from  the  effects  of  arsenic  poison,  administered  in  coffee, 
on  Wednesday  evening,  May  31st,  1876,  and  that  we  believe  the 
same  was  administered  by  Allen  C.  Laros." 

A  warrant  was  issued  at  once.  Young  Laros  was  arrested  as  he 
lay  sick  in  bed,  and  taken  to  the  county  prison  at  Easton,  Pennsyl- 
vania. The  prisoner  was  about  twenty-six  years  of  age,  a  little 
under  the  medium  height,  and  slightly  built.  He  had  received  an 
ordinary  common-school  education,  and  was  fairly  intelligent.  He 
was  temperate,  industrious,  and  moral,  and  was  a  church  member. 
He  was  always  disposed  to  be  somewhat  reticent,  and  spent  much  of 
his  time  alone.  He  was  of  respectable  parentage,  of  healthful  sur- 
roundings, of  good  moral  and  intellectual  training,  a  teacher  of  the 
young  in  one  of  the  public  schools  in  his  own  township.  He  was, 
however,  an  epileptic,  the  epilepsy  manifesting  itself  more  than  four 


480  •  PSYCHOLOGICAL   MEDICINE. 

years  before  the  poisoning  took  place,  and  had  continued,  by  succes- 
sive steps  of  longer  or  shorter  duration,  until  the  time  of  the  poison- 
ing. For  three  weeks  before  this  time,  almost  daily,  he  Avas  so 
afflicted  with  epileptic  convulsions  as — so  counsel  for  defence  claimed 
— to  dethrone  his  reason  and  destroy  the  powers  of  his  mind.  It 
was  claimed  and  proved  that,  on  the  Saturday  previous  to  the  crime, 
he  was  afHicted  with  convulsions ;  that  he  had  them  on  Sunday, 
Monday,  Tuesday  (the  day  the  Commonwealth  claimed  he  bought 
the  poison),  on  Wednesday  (the  day  of  the  poisoning),  and  on  Thurs- 
day and  Friday,  immediately  after  it.  After  his  confinement  in  pri- 
son he  was  similarly  affected  by  these  convulsions,  varying  in  dura- 
tion from  a  few  minutes  to  several  hours.  During  the  continuance 
of  the  convulsions  he  was  totally  unconscious.  Before  and  since  his 
confinement,  for  a  period  of  several  hours  after  these  convulsions  had 
passed  away,  his  mind  was  cloudy  and  confused,  and  his  conversation 
and  acts  not  responsible. 

My  own  opinion  has  always  been  that,  in  the  event  of  a  criminal 
act  by  an  epileptic,  we  should  suspect  mental  disorder,  and  that,  in 
the  absence  of  any  strong  personal  motive,  there  should  be  immunity 
of  punishment  to  epileptics  for  acts  committed  within  three  days  be- 
fore or  after  an  attack,  such  insane  acts  being  to  me  the  evidence  of 
an  insane  mind.  Such  persons  are,  I  think,  able  to  conduct  their 
business,  and  perform  their  duties,  and  continue  their  pursuits  in  all 
respects  like  other  people,  except  at  the  time  of  seizure.  In  the  case 
of  young  Laros  there  was  an  inherited  tendency  to  insanity  and  ner- 
vous diseases  for  several  generations,  and  in  many  branches  of  the 
family  of  the  prisoner — grandfather,  grandmother,  and  maternal  aunt. 
These  circumstances  all  contributed  to  lower  the  grade  of  his  offence, 
even  if  it  was  not  the  offspring  of  decided  insanity. 

While  young  Laros  was  in  prison  awaiting  trial  every  possible  ex- 
periment was  tried  to  ascertain  if  he  were  conscious  while  in  the  con- 
vulsion, and  every  conceivable  test  applied  to  see  if  the  prisoner  were 
feigning.  The  prison  physician,  during  the  first  paroxysm  he  wit- 
nessed, suddenly  thrust  the  blade  of  a  sharp  knife  into  the  prisoner's 
hand,  and  no  sensation  was  manifested.  A  heated  key  was  next  ap- 
plied. Then  the  flame  of  a  lighted  lamp  was  held  to  the  sole  of  his 
bare  foot,  and  still  not  a  quiver  of  sensation  followed.  Melted  seal- 
ing-wax was  dropped  upon  the  bare  skin  so  that  the  sealing-wax 
burned  into  the  skin,  and  no  indication  of  pain  was  shown.  Nothing 
that  science  could  suggest  was  left  untried  to  detect  imposture,  if  any 


STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      48 1 

existed,  but  all  these  tests  failed  to  detect  any  feigning  on  the  part 
of  the  prisoner.  At  the  trial,  Dr.  John  M.  Junkin,  of  Easton,  Penn- 
sylvania, testified  that  he  was  called  upon  to  visit  Martin  Laros  on 
the  morning  of  June  ist.  Reached  there  about  three  o'clock  and, 
concluding  from  the  symptoms  that  they  were  all  suffering  from  ar- 
senical poison,  he  gave  stimulants  and  hydrated  peroxide  of  iron.  He 
found  his  patients  vomiting  and  purging,  and  gave  it  as  his  opinion 
that  the  death  of  Martin  Laros  was  caused  by  arsenic.  During  the  pro- 
gress of  the  trial  various  persons  testified  to  having  been  aware  of  the 
prisoner's  infirmity,  and  the  deputy  warden  of  the  county  prison  testi- 
fied as  to  the  nature  of  the  attacks  while  Laros  was  in  prison.  He 
described  finding  the  prisoner  "  struggling  in  his  cell  in  a  fit,"  with 
his  face  very  white,  eyes  partly  closed,  the  hands  clenched,  with  the 
thumbs  inside,  and  that  he  heard  the  prisoner's  teeth  gritting.  He 
also  described  incoherent  and  apparently  insane  conversation  of  the 
prisoner,  and  hallucinations  of  sight.  The  prison  physician  also  tes- 
tified that  he  found  him — with  a  weak  and  feeble  pulse  and  cool, 
pale  skin — acting  in  a  wild,  incoherent  manner ;  talking  about  fish- 
ing, seeing  water-snakes,  and  other  nonsenical,  insane  conversation. 
Any  bright  object,  he  would  endeavor  to  get  hold  of  His  pockets 
were  stuffed  with  bits  of  paper  and  such  things.  He  tried  to  get  the 
warden's  shoe-buckles  and  the  bright  tips  of  the  doctor's  shoestrings. 
The  doctor  also  testified  that  he,  the  prisoner,  did  not  appear  to  have 
good  control  over  his  muscular  movements.  The  doctor  also  de- 
scribed various  epileptic  convulsions  which  he  witnessed,  and  testi- 
fied as  to  the  total  unconsciousness  of  the  prisoner  during  the  parox- 
ysms. He  also  testified  to  seeing  the  prisoner  six  to  eight  hours 
before  an  attack,  when  he  appeared  dull,  and  gave  imperfect  answers, 
and  complained  of  pain  in  the  head.  The  prisoner's  condition  while 
under  observation,  coupled  with  the  testimony  of  his  friends  as  to  his 
previous  symptoms  and  condition,  led  all  unprejudiced  observers  to 
believe  that  he  was  mentally  unsound.  Dr.  John  Curwen,  the  Su- 
perintendent of  the  Pennsylvania  State  Lunatic  Asylum,  testified 
that  he  considered  frothing,  swelled  veins  in  the  neck,  and  lividity 
of  face  as  essential  symptoms,  and  without  these  he  would  doubt  the 
genuineness  of  the  epilepsy,  although,  on  re-examination  by  counsel 
for  defence,  he  admitted  that  these  signs  might  possibly  be  absent 
in  cases  even  of  pure  epilepsy.  Dr.  Curwen  was  expert  for  the 
Commonwealth  of  Pennsylvania.     The  jury  in  this  case  rendered  a 

31 


482  PSYCHOLOGICAL   MEDICINE. 

verdict  of  murder  in  the  first  degree,  and  the  prisoner  was  duly  sen- 
tenced to  be  hung. 

The  death-warrant  was  signed,  but  a  writ  of  error  was  sued  out  in 
the  Supreme  Court  of  Pennsylvania,  which  operated  as  a  supersedeas, 
and  the  governor  recalled  the  warrant.  The  counsel  for  the  defence 
then  presented  to  the  court  a  petition  alleging  mental  unsoundness, 
and  asked  for  a  commission  to  inquire  into  the  matter  and  ascertain 
whether  the  prisoner  was  a  proper  subject  for  capital  punishment. 
The  commission  appointed  by  the  court  consisted  of  Dr.  William 
Pepper,  of  Philadelphia,  Dr.  S.  Preston  Jones,  also  of  that  city,  asso- 
ciated with  Dr.  Kirkbride,  at  his  asylum,  and  Hon.  Henry  A.  Ross, 
a  lawyer  of  Pennsylvania. 

The  commission  spent  a  month  or  more  in  taking  testimony  and 
making  a  personal  examination  of  the  prisoner.  They  made  a 
unanimous  report  to  the  court  that  he  was  an  epileptic  and  men- 
tally irresponsible,  that  he  should  not  be  visited  with  capital  punish- 
ment, and  recommended  his  removal  to  an  asylum.  Thereupon  the 
court  ordered  him  to  be  removed  to  the  State  Lunatic  Asylum,  at 
Harrisburg,  Pennsylvania,  of  which  Dr.  Curwen  is  superintendent. 
After  confinement  for  a  period  of  about  two  years  he  escaped,  and 
subsequently  was  captured  in  Arkansas,  or,  rather,  he  surrendered 
himself  to  the  authorities  and  requested  them  to  "  send  him  back  to 
this  country  to  be  hung."  He  didn't  want  to  be  returned  to  the 
asylum.  He  was  returned  to  the  asylum,  and  about  six  months  ago 
he  escaped  from  there  a  second  time,  and  nothing  is  now  known  of 
his  whereabouts. 

The  able  efforts  in  his  behalf  and  in  the  cause  of  humanity  are 
owing  to  the  exertions  of  his  counsel,  Henry  W.  Scott,  Esq.,  of  Eas- 
ton,  Pennsylvania.  Upon  his  examination  the  prisoner  declared  that 
his  father  and  mother  were  both  living  and  that  his  father  was 
making  a  door  when  he  left  home.  One  of  the  prisoner's  brothers 
was,  up  to  the  time  of  his  death,  a  quiet,  uncommunicative,  and  retir- 
ing man,  and  he  died  by  hanging  himself  without  apparent  motive  or 
cause.  Young  Laros  was  a  person  of  uniformly  mild  and  tractable 
disposition,  who  was  brought  up  amid  the  softening  and  restraining 
influences  of  a  pious  and  affectionate  family  and  away  from  demoral- 
izing surroundings  or  vicious  companions.  This  outrageous  and 
enormous  crime  was  very  likely  the  outcome  of  mental  disorder 
which  had  depraved  and  eclipsed  the  moral  faculties.  Yet  the  judge 
and  jury  deliberately  arrived  at  a  verdict  which  doomed  this  unhappy 


STATES    OF    UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      483 

creature  to  the  scaffold.  In  reviewing  this  case  psychologically  we 
have,  as  I  have  said,  a  mild-mannered  boy,  of  previous  exemplary 
behavior,  uniformly  kind  and  affectionate,  suddenly  developed  into 
an  inhuman  monster  of  depravity.  For  four  years  he  had  been 
afflicted  with  epilepsy,  and  we  must  bear  in  mind  the  tendency  of 
epilepsy  to  generate  the  insane  impulse  to  crime.  We  must  also 
bear  in  mind  that  there  are  on  record  many  homicides  committed  by 
epileptically  insane  persons  under  every  circumstance  of  apparent 
motive  and  design.  There  was  a  rapid  succession  of  the  spasms 
shortly  before  and  after  the  Wednesday  night  on  which  the  family 
were  taken  sick.  These  attacks  had  been  noticed  more  particularly 
during  the  few  months  preceding  the  tragedy,  and  they  had  occurred 
with  startling  distinctness  and  frequency,  and  on  the  very  evening  of 
the  murder  he  was  unquestionably  under  the  influence  which  pre- 
cedes and  follows  the  epileptic  paroxysm  of  epileptic  insanity.  The 
experts  for  the  Commonwealth  in  this  case  adopted  the  typical  case 
of  epilepsy  as  the  unvarying  standard  by  which  the  disease  is  to  be 
ascertained,  and  it  was  only  under  the  most  rigid  cross-examination 
that  they  would  modify,  in  some  degree,  this  position.  The  symp- 
toms of  epilepsy  are  not,  however,  invariable.  There  may  be  every 
variety,  from  the  simply  vertiginous  to  the  most  demonstrative  mus- 
cular and  nervous  spasms.  The  epileptic  may  be  pallid  or  purple- 
hued,  the  pupils  may  contract  or  dilate,  the  fingers  may  be  clenched 
or  extended,  there  may  be  foaming  at  the  mouth  or  it  may  be  absent. 
That  some  of  the  symptoms  of  the  most  decided  and  impressive 
type  are  not  present  is  no  proof  that  the  disease  is  not  epilepsy. 
The  disorder  of  the  intellect  which  accompanies  epilepsy  is  similar 
to  that  we  meet  with  in  chronic  insanity,  and  while,  of  course,  it  is 
not  the  invariable  rule,  yet  in  my  own  practice  I  have,  in  the  great 
majority  of  cases,  observed  enfeeblement  of  memory  and  intellectual 
powers  amounting  to  insanity.  While  an  epileptic  may  be  very 
intelligent,  I  do  not  believe  that,  either  during  the  attack  or  for  an 
indefinite  period  subsequently,  the  mental  faculties  are  under  the 
control  of  the  patient.  The  patient,  particularly  as  the  effect  of  the 
lighter  seizures,  becomes  very  irritable  indeed,  and  there  are  in- 
stinctive impulses,  I  think,  to  acts  of  violence.  The  confused  rec- 
ollection of  what  has  happened  and  the  unconsciousness  of  the 
gravity  of  his  acts  is,  I  think,  diagnostic  of  the  mental  state  of  the 
epileptic,  and  should  be  considered  as  the  essential  characteristic  of 
it.     The  epileptic,  in  the  majority  of  cases,  seems  to  automatically 


484  PSYCHOLOGICAL    MEDICINE. 

obey  the  impulses  generated  by  his  disease,  and  seems  utterly  power- 
less to  resist  them,  even  though  they  impel  to  criminal  deeds.  This 
constant  disturbance  of  the  affective  and  intellectual  faculties  which 
is  manifest  after  the  paroxysm,  may  last  during  the  greater  part  of 
the  interval  between  the  fits,  and  this  is  a  medico-legal  point  of  great 
importance.  There  may  be  abortive  epileptiform  attacks,  where  there 
are  no  convulsions  and  where  there  is  no  complete  loss  of  conscious- 
ness,— a  sort  of  epileptic  vertigo, — and  yet  such  persons  have  com- 
mitted sudden  deeds  of  violence,  and  were  utterly  unable  to  remem- 
ber the  circumstances  afterwards. 

I  think  there  are  cases  where  the  petit  inal  of  epilepsy  may  con- 
tinue for  hours,  where  no  overt  act  happens,  and  where  there  is  no 
motive  for  falsification.  There  is  also,  dating  from  the  close  of  the 
grand  inal  an  insidious  and  obscure  state  resembling  healthy  men- 
talization,  and  differing  from  it  only  by  a  complete  unconscious- 
ness compatible  with  many  rational  doings.  This  state  follows  the 
convulsion,  and  is  very  dangerous  to  those  around  the  patient.  The 
acts  in  this  state  are  closely  allied  to  the  state  of  unconsciousness  in 
somnambulism.  There  is  no  knowledge  or  recollection  of  events 
that  occur,  or  of  overt  acts  that  may  be  committed  during  this  state. 
Baillarger  relates  the  case  of  a  vine-dresser  near  Lyons,  France,  who 
was  seized  with  a  fi.t  of  shivering,  and  who  took  up  a  mattock  and 
killed  three  of  his  children,  and  not  but  a  few  rods  from  that  spot  he 
killed  his  wife  and  last  child.  He  was  much  attached  to  his  wife 
and  children.  Falret  relates  a  case  of  a  youth  liable  to  vertiginous 
seizure,  so  severe  as  to  occasion  him  to  grasp  the  nearest  object  for 
support,  who  attempted  to  poison  himself,  was  not  excitable,  would 
leave  his  business  abruptly,  walk  seventy-five  miles  from  Paris, 
taking  no  food  for  forty-eight  hours,  would  forget  his  ordinary  work, 
would  walk  during  the  night,  wounded  a  lady  in  the  street  and  re- 
membered nothing  of  the  assault.  The  unconsciousness  or  mental 
weakness  the  sequela  of  epilepsy  permits  of  the  existence  of  delu- 
sions— morbid  mono-ideaism,  irresistible  impulse,  and  murderous  in- 
stincts, Avhich  regulate  automatically  the  volition  and  acts  of  the 
patient.  This  is  a  scientific  and  well-attested  fact.  There  is  only 
partial  responsibility  in  this  state. 

The  Mental  Condition  in  Hypnotism.'^ — Dr.  D.  Hack  Tuke,  in  his 
address  on  this  subject  before  the  Medico-Psychological  Association 

*  I  would  define  hypnotism  as  a  morbidly  profound  sleep  of  the  cortex  of  the  brain 
while  the  basal  ganglia  remain  unaffected  and  in  their  normal  condition. 


STATES    OF   UNCONSCIOUSNESS — SOMNAMBULISM — CATALEPSY,  ETC.      485 

in  London,  February  21st,  1883,  said  that  he  had  tried  to  form  a 
clear  idea  as  to  the  cerebro-mental  condition  of  hypnotized  persons. 
The  data  upon  which  we  have  to  form  an  opinion  or  construct  a 
theory  are  : 

1st.  The  condition  necessary  to  induce  the  state  in  question. 

2d.  The  objective  symptoms  of  the  hypnotized  so  far  as  we  can 
observe  them ;  and, 

3d.  The  subjective  state  experienced  and  described  by  himself  (the 
hypnotized  person),  in  those  instances  in  which  memory,  more  or 
less  distinct,  is  retained  of  what  has  been  present  to  the  mind  during 
the  hypnotic  condition. 

I .  As  to  the  Condition  Necessary  to  Induce  the  Hypnotic  State. — Star- 
ing at  a  disk  or  some  well-defined  object  is  a  very  frequent  method. 
Other  methods  are  also  effective.  The  monotonous  sensory  impres- 
sions produced  by  passes,  by  counting  up  to  several  hundred  figures, 
by  listening  to  the  ticking  of  a  watch,  etc.  We  may  throw  ourselves 
into  an  hypnotic  state  in  attempting  to  go  to  sleep.  The  principles 
common  to  the  various  modes  of  hypnotism  is  on  the  physical  side,  the 
stimulation,  more  or  less  prolonged,  of  a  sensory  nerve  in  close  relation 
to  the  brain,  calcidated  to  idtimately  exhaust  some  portion  of  that  organ, 
and  on  the  mental  side,  the  riveting  the  attention  on  one  idea.  Looking 
at  an  object  is  not  essential,  for  a  blind  person  may  be  hypnotized, 
and  in  susceptible  persons  the  merely  expecting  to  be  hypnotized  is 
sufficient  to  induce  it,  the  expectation  in  this  case  involving  the  con- 
centration of  the  attention  to  one  point. 

Mr.  W  North,  Lecturer  on  Physiology  at  Westminster  Hospital, 
thus  describes  his  own  feelings  while  hypnotized :  "  I  have  not  the 
smallest  doubt,  that  at  first  I  succeeded  in  abstracting  myself,  as  it 
were,  from  surrounding  circumstances.  I  had  been  reading  very 
hard  for  days  past  on  the  subject  of  intestinal  digestion  in  relation 
to  the  bacteria  produced,  and  I  pictured  to  myself  the  interior  of  the 
intestine  and  its  contents ;  then  I  tried  to  picture  a  special  form  of 
bacteria,  and  while  I  was  engaged  in  contemplating  its  changes  of 
form  I  seemed  to  lose  all  consciousness  of  persons  around  me."  On 
a  subsequent  trial  being  made  he  looked  at  his  boot,  and  thus  de- 
scribed the  process :  "  I  ultimately  succeeded  in  fixing  my  attention  on 
six  points  of  light  reflected  upon  my  boot,  and  having  some  minute 
resemblance  in  position  to  the  constellation  Orion.  After  looking 
fixedly  at  this  for  what  seemed  to  me  a  very  long  time,  the  idea  of 
the  constellation  vanished,  and  its  place  was  taken  by  the  outline  of 


486  PSYCHOLOGICAL   MEDICINE. 

the  lower  part  of  the  face  of  a  friend.  All  I  could  see  was  his  beard 
and  mouth  and  part  of  his  nose  and  one  cheek,  the  rest  was  cut  off 
by  a  broad  black  area;  the  details  were  tolerably  vivid." 

The  voluntary  surrender  of  the  will — the  subject  placing  himself 
passively  in  the  hands  of  the  operator,  is  also  an  important  factor  in 
nearly  all  the  processes.  It  is  the  initial  step  to  the  subsequent 
abandonment  of  the  will  of  the  subject  to  that  of  another.  M. 
Richet,  of  the  Salpetriere,  has  shown  that  the  subject  may  be  sur- 
prised, and  even  rendered  cataleptic,  the  moment  his  attention  is  in 
the  least  arrested.  He  is  seized,  and,  as  it  were,  instantaneously 
petrified,  whatever  efforts  he  makes  to  resist  the  influence.  M.  Richet 
constantly  produces  hypnotism  by  throwing  a  brilliant  electric  light 
upon  the  face  of  persons  not  expecting  it,  or  by  striking  a  gong 
which  had  been  concealed.  An  hysterical  or  neurotic  subject  has 
been  transformed  into  a  statue  by  a  blow  or  the  concealed  gong  at 
the  Salpetriere. 

2.  The  Objective  Symptoms  of  the  Hypnotized. — These  vary  with 
the  stage  or  type.  Charcot,  Richet,  Tamburini,  and  Sepelli  recog- 
nize three  fundamental  types,  the  cataleptic,  the  lethargic,  and  the 
somnambulistic.  In  the  first  the  limbs  retain  the  positions  in  which 
they  were  placed,  for  a  considerable  time  and  without  effort;  in  the 
second  (the  lethargic),  the  muscles  which  are  relaxed  are  found  to 
have  the  remarkable  property  of  contracting  in  a  most  definite  way 
under  gentle  mechanical  application ;  in  the  third  (the  somnambu- 
listic), the  state  of  the  subject  answers  much  more  to  what  is  un- 
derstood, as  the  so-called  magnetic  or  mesmeric  sleep.  Contraction 
of  the  limbs  can  be  produced,  but  they  are  of  a  different  character 
from  those  in  the  cataleptic  form,  or  the  excitability  of  the  muscles 
in  the  lethargic  state. 

Pupils. — The  pupils  exhibit  strabismus  and  contraction,  and  after- 
wards are  widely  dilated  and  sluggish,  an  indication  of  the  func- 
tional activity  of  the  medulla,  as  regards  the  sympathetic  as  well  as 
the  respiratory  centre. 

Cerebral  Circulation. — Ophthalmoscopic  examination  by  Professor 
Forster  of  Heidenhain's  patient  showed  that  there  was  no  contrac- 
tion of  the  vessel  as  Heidenhain  expected  to  find,  as  his  theory  had 
been  that  anaemia  caused  the  sleep.  That  hyperaemia  of  the  brain 
is  not  inconsistent  with  hypnotism  was  proved  by  hypnotizing  a  gen- 
tleman (Heidenhain's  brother),  who  had  inhaled  nitrite  of  amyl. 
The  respiration  and  pulsation  are  quickened  at  first.     Professor  Tam- 


STATES    OF   UNCONSCIOUSNESS SOMNAMBULISM — CATALEPSY,  ETC.      48/ 

burini  used  the  pneumograph,  and  he  found  the  frequency  of  respi- 
ration to  be  doubled  at  first,  and  the  inspiratory  pause  suppressed. 
These  tracings  are  useful  in  detecting  simulation.  With  the  cata- 
leptic subject  the  tracing  is  uniform  in  character  from  beginning  to 
end.  With  the  simulator,  on  the  contrary,  it  is  composed  of  two 
distinct  parts.  At  the  beginning,  respiration  is  regular  and  normal ; 
in  the  second  stage,  that  which  corresponds  to  the  indications  of 
muscular  fatigue,  irregularity  in  the  rhythm  occurs  with  deep  and 
rapid  depressions,  manifest  indications  of  the  disturbance  of  the  res- 
piration caused  by  the  effort  to  simulate.  Professor  Tamburini  made 
careful  pulse  tracings  also.  The  rise  in  the  pulse  is  100  per  cent. 
The  myograph,  the  pneumograph,  and  the  sphygmograph  are  most 
valuable  means,  placed  at  our  disposal  by  modern  invention,  for  ob- 
taining trustworthy  records  of  the  objective  symptoms  of  hypnotism. 
There  is  heightened  reflex  action.  The  tendon  reflexes  may  be 
normal  or  exaggerated.  Richer  states  than  in  the  lethargic  type 
they  are  much  exaggerated,  in  the  cataleptic  type  they  are  dimin- 
ished, and  in  the  somnambulistic  type  normal.  There  is  galvanic 
reaction. 

3.  Subjective  Symptoms  described. — Sensation  of  pain  is  deadened 
or  suspended.  Anaesthesia  is  produced.  Mr.  North  said  that  a  pin 
plunged  into  his  hand  nearly  up  to  its  head,  felt  as  if  a  match  or 
some  blunt  instrument  were  pressing  against  the  hand.  When  he 
was  roused  it  hurt  him  considerably  to  withdraw  the  pin.  The  spe- 
cial senses  are  interfered  with  or  abolished.  They  may  be  either 
heightened  or  abolished  in  different  cases.  Sight,  is  partially  affected. 
The  subject  sees,  though  confusedly,  that  which  is  immediately 
around  him,  but  has  a  very  vague  or  no  perception  at  all  of  what  is 
beyond  this  range.  Some  subjects  describe  a  play  of  colors  before 
the  eyes.  Hearing  is  not  affected.  Taste  is  suspended.  There  may 
be  no  unconsciousness  whatever  in  some  instances,  and  the  subject 
may  appear  like  other  people.  A  certain  susceptibility  to  impres- 
sions on  the  mental  side  and  to  rigidity  of  the  limbs  on  the  physical 
side  may  be  all  that  marks  the  state  of  the  subject.  Is  it  that  the 
cerebral  cortex  is  just  sufficiently  weakened  in  function  to  have  lost 
its  supremacy,  without  parting  with  its  more  secondary  offices? 

Volition. — There  is  no  spontaneity*  in  hypnotized  persons.  Voli- 
tion is  suspended. 

Extreme  Susceptibility  to  Outside  Suggestions. — The  subject  hyp- 
notized is  without  any  will-power,  and  at  the  mercy  of  any  sugges- 


488  PSYCHOLOGICAL   MEDICINE. 

tions  however  absurd.  Hallucinations  are  easily  induced.  A  person 
may  eat  heartily  while  hypnotized,  and  their  visceral  sensations  will 
not  suffice  to  inform  them,  so  that  they  will  wish  for  the  next  regular 
meal  as  if  they  had  not  eaten.  Richet,  of  France,  says  :  "  The  som- 
nambulist has  a  perfect  memory,  a  very  lively  intelligence,  and  an 
imagination  which  constructs  the  most  complex  hallucination."  The 
great  fact  in  mesmeric  sleep  is  that  will  and  consciousness  are  sus- 
pended, and  the  brain  placed  in  the  condition  of  the  true  spinal  or 
reflex  S3-stem.  There  is  a  reduction  to  a  mere  automatic  condition. 
Heidenhain  holds  that  the  cause  of  the  phenomena  of  hypnotism 
lies  in  the  inhibition  of  the  activity  of  the  ganglion  cells  of  the  cere- 
bral cortex  by  prolonged  stimulation  of  the  sensory  nerves  of  the 
face,  or  the  auditory  or  optic  nerve.  A  sensory  nerv^e  may  certainly 
inhibit  the  brain  centres,  and  this  inhibition  is  the  starting-point  of 
hypnotism. 

Coiicliisio7is. — I.  There  may  be  consciousness  during  the  state  of 
hypnotism,  and  it  may  pass  rapidly  or  slowly  into  complete  uncon- 
sciousness as  in  the  somnambulistic  state ;  the  manifestations  not 
being  dependent  upon  the  presence  or  absence  of  consciousness, 
which  is  merely  an  epiphenomenon. 

2.  A'oluntar}'  control  over  thought  and  action  is  suspended. 

3.  The  reflex  action,  therefore,  of  the  cerebral  cortex  to  sugges- 
tions from  without,  so  long  as  any  channel  of  communication  is 
open,  comes  in  play. 

4.  While  the  consciousness  is  retained,  the  perception  of  the  reflex 
or  automatic  cerebral  action  conveys  the  impression  that  there  are 
two  egos. 

5.  Some  of  the  mental  functions,  as  memory,  may  be  exalted,  and 
there  may  be  vivid  hallucinations  and  delusions. 

6.  Unconscious  reflex  mimicry  may  be  the  only  mental  phenomena 
present,  the  subject  copying  minutely  everything  said  or  done  by  the 
person  with  whom  he  is  en  rapport. 

7.  Impressions  from  without  may  be  blocked  at  different  points  in 
the  encephalon,  according  to  the  areas  affected  and  the  completeness 
with  which  they  are  hypnotized ;  thus,  an  impression  or  suggestion 
may  take  the  round  of  the  basal  ganglia  only,  or  may  pass  to  the  cor- 
tex, and,  having  reached  the  cortex,  may  excite  ideation  and  reflex 
muscular  actions,  with  or  without  consciousness,  and  wholly  inde- 
pendent of  the  will. 

8'.  There  may  be  in  different  states  of  hypnotism  exaltation  or  de- 


STATES  OF   UNCONSCIOUSNESS  —SOMNAMBULISM — CATALEPSY,  ETC.      489 

pression  of  sensation,  and  the  special  senses.  There  is  a  peculiar 
abnormal  mental  condition  presented  in  hypnotism,  closely  allied  to 
mental  disease,  and  full  of  interest  to  students  of  mental  science.  The 
subject  has  been  scientifically  studied  by  James  Braid,  of  Manchester, 
in  1843  ;  Esdaile,  in  India,  in  1846 ;  Girard  Teulon  and  Demarquay, 
in  i860;  Richet,  in  1875;  Charcot,  in  1878;  and,  in  or  about  1880,  by 
the  late  Dr.  George  M.  Beard,  Drs.  Weinhold,  Preyer,  Berger,  Griitz- 
ner,  and  Heidenhain,  and  Dr.  H.  Charleton  Bastian.  We  may  fail  at 
first  with  a  subject,  and  after  a  few  trials  he  may  make  an  excellent 
subject  for  experimentation.  Bastian  says  that  persons,  who  have  been 
once  hypnotized,  can  in  general  be  again  brought  with  comparative 
ease  into  the  same  condition,  and  the  facility  of  hypnotizing  such 
persons  goes  on  increasing  after  each  operation,  owing  to  the  exist- 
ence of  a  predisposing  mental  state.  A  condition  of  excited  expect- 
ancy is  a  decidedly  favoring  mental  state. 

The  simplest  condition  necessary  to  induce  the  hypnotic  or 
trance-like  condition  is  to  make  the  subject  look  fixedly  for  a  few 
seconds  at  a  bright  object,  held  by  the  operator  at  about  eight  to 
fifteen  inches  above  the  eyes,  at  such  a  distance  above  the  forehead 
as  may  be  necessary  to  produce  the  greatest  possible  strain  upon  the 
eyes  and  eyelids,  and  enable  the  patient  to  maintain  a  steady,  fixed 
stare  at  the  object.  We  must  tell  the  subject  to  keep  his  eyes  steadily 
fixed  on  this  object  and  his  mind  riveted  upon  the  image  of  it.  In 
some  persons,  after  fifteen  or  twenty  seconds,  we  shall  find  a  decided 
cataleptic  state  induced,  so  that  the  limbs  have  the  tendency  to  re- 
main in  the  position  in  which  we  place  them,  and,  if  not,  we  may 
gently  request  the  patient  to  keep  his  limbs  in  the  position  in  which 
we  have  placed  them.  The  pulse  now  quickens  and  the  limbs  shortly 
become  rigid.  By  prolonging  this  process  we  induce  a  profound 
sleep,  or  trance,  in  which  there  is  complete  anaesthesia.  Esdaile,  in 
India,  performed  numerous  operations  on  Hindoos  with  absence  of 
all  pain  while  hypnotized.  The  therapeutic  value  of  hypnotism  has 
never  yet  been  thoroughly  tested,  and  the  future  may  develop  facts 
of  much  interest  and  value. 


490  PSYCHOLOGICAL    MEDICINE. 


•    CHAPTER  XXVI. 

CEREBRAL   AND    SPINAL   ANEMIA. 

The  occurrence  of  cerebral  and  spinal  anaemia  is  becoming  so  fre- 
quent among  American  women  and  is  the  cause  of  so  much  of  their 
ill  health  and  lassitude,  that  I  propose  to  investigate  in  this  chapter 
its  symptoms,  causes,  morbid  anatomy,  and  treatment,  feeling  sure 
that  so  common  and  troublesome  an  affection  cannot  fail  to  be  of  in- 
terest to  the  majority  of  the  profession. 

We  are  applied  to  for  treatment  by  pale,  colorless  women,  with 
cold  skin,  complaining  of  headache  of  a  limited  nature,  usually  re- 
lieved by  lying  down,  and  exaggerated  by  either  physical  or  mental 
effort.  These  patients  have  little  muscular  power ;  and  we  sometimes 
find  symptoms  of  anaesthesia.  The  patients  all  complain  of  drowsi- 
ness. The  majority  of  these  patients  will  be  found,  when  spinal 
anaemia  is  present,  to  have  tenderness  over  one  or  more  points  of 
the  vertebral  column,  which  is  increased  by  pressure.  The  pain  de- 
veloped by  such  pressure  may  be  either  dull  or  sharp  in  nature.  We 
may,  in  rare  cases,  find  tenderness,  on  pressure,  over  the  entire  spine. 
Neuralgia  is  also  a  very  prominent  symptom,  and  may  be  experi- 
enced in  the  head,  face,  neck,  shoulders,  and  upper  extremities  when 
the  cervical  and  dorsal  regions  of  the  spinal  cord  are  implicated ; 
while  the  neuralgic  pain  attacks  the  pelvis  and  the  lower  extremities 
when  the  anaemia  implicates  the  lumbar  region  of  the  spine.  If  the 
neuralgic  pain  is  in  the  head,  it  may  vary  in  its  location,  being  some- 
times in  one  part  of  the  head  or  face  and  sometimes  in  another,  and 
sometimes  on  one  side  only.  In  the  head,  it  may  be  limited  to  a 
small  spot.  This  pain  is  relieved  by  lying  down  and  keeping  per- 
fectly still.  It  may  be  very  continuous  and  exasperating,  and  may 
be  accompanied  by  nausea  and  vomiting.  The  extremities  are  veiy 
apt  to  be  cold,  and  sleep  is  restless  and  disturbed.  These  patients 
look  very  worn  and  thin.  These  patients  may  have  prolonged  mus- 
cular contractions,  especially  oFthe  lower  limbs  and  of  the  hands.  I 
have  at  present  a  lady  from  Mississippi  under  my  care  who  suffers 
from  spinal  anaemia  and  hysteria,  and  who,  before  leaving  her  home 
in  Mississippi,  had  been  for  a  week  in  a  cataleptic  state,  whose  fingers 
and  thumbs  are  tightly  closed  upon  the  palms,  and  have  been  so  for 
some  months.     This  contraction  is  with  her,  as  it  is  with  all  cases, 


CEREBRAL   AND   SPINAL   ANEMIA.  49 1 

painless.  It  came  on  suddenly,  and  I  have  confidently  predicted  that 
when  the  spinal  anaemia  is  cured  it  will  cease  as  suddenly  as  it  came 
on.  This  young  lady  was  suffering  from  complete  hysterical  paralysis 
when  she  entered  my  hospital,  and  had  not  spoken  for  a  long  time. 
The  muscles  were  attenuated  by  disuse,  her  expression  was  idiotic, 
and  she  could  not  walk  a  step  and  would  not  utter  a  sound.  Under 
the  constant  galvanic  current,  the  negative  pole  to  the  sixth  cervical 
vertebra  and  the  positive  pole  to  the  coccyx,  the  ascending  current  from 
thirty-two  cells  being  used;  hypodermics  of  strychnia;  the  actual 
cautery  to  the  neck  twice  ;  a  full  diet,  blisters  to  the  spine,  and  tonics ; 
she  now  walks  well ;  her  muscles  have  regained  their  tone ;  she  reads 
well ;  can  write  a  little,  although  she  holds  a  pen  very  clumsily, 
owing  to  the  contraction,  and  is  making  an  excellent  recovery.  Re- 
specting this  patient's  obstinate  silence,  I  received  the  following  from 
her  family  physician,  under  date  of  August  /th,  1882 : 

Dear  Doctor, — Your  favor  of  the  25th  inst.  reached  me  seven  days  ago,  but  urgent 

professional  engagements  have   interfered  with   my  answering  it  sooner.     Miss 's 

silence,  to  which  you  refer,  and  ask  if  she  has  "  ever  had  any  dominant  idea  or  emotion  " 
which  would  account  for  it,  has  been  for  years  a  marked  peculiarity,  and,  as  far  as  I  know, 
has  been  a  habit  with  her  among  strangers.  I  am  not  aware  of  any  depressing  "  emotion 
or  idea"  which  might  explain  it,  or  of  any  taint  ofinsanity  in  her  family.  In  a  general 
way,  I  am  inclined  to  fall  back  on  the  idea  of  family  taint  to  explain  her  peculiarities.  I 
think  those  who  have  known  best  would  say  that  she  is  a  "  girl  of  peculiar  mental  con- 
stitution, even  when  well,"  as  you  suggest,  etc.,  etc. 

It  is  evident,  from  this  letter,  that  my  patient  was  one  of  those  in- 
dividuals who  had  inherited  a  marked  nervous  constitution.  An- 
other similar  case  from  Missouri  had  prolonged  muscular  contrac- 
tions of  the  lower  limbs.  She  had  marked  spinal  anaemia.  The 
contractions  suddenly  disappeared  as  she  got  better,  she  made  an 
excellent  recovery. 

At  times  we  find  hyperaesthesia  existing,  either  of  the  whole  or  of 
a  part  of  the  body,  or  limited,  in  some  cases,  to  the  organs  of  special 
sense.  Occasionally  we  see  convulsive  movements,  and  also  affec- 
tions of  the  larynx  and  air-passages,  and  alimentary  canal.  Some 
patients  with  cerebral  anaemia  give  a  history  of  attacks  of  dizziness 
and  fainting  fits,  while  others  complain  of  intense  irritability  and 
disturbances  of  sensibility.  These  latter  patients  are  very  sensitive 
to  light  and  sound,  and  have  flashes  before  the  eyes.  There  may  be 
delirium,  convulsions,  and  coma,  and  even  attacks  of  acute  mania, 
in  the  worst  cases  of  cerebral  anaemia.     Patients  are  very  apathetic, 


492  PSYCHOLOGICAL    MEDICINE. 

and  they  have  much  mental  lassitude.  They  are  inclined,  as  I  have 
said,  to  sleep,  but  their  sleep  is  of  a  disturbed  character,  and  they 
are  annoyed  by  frightful  dreams.  In  nearly  every  case  of  cerebral 
anaemia,  we  meet  with  disturbances  of  the  mind  ranging  from  slight 
hysterical  symptoms  to  acute  maniacal  paroxysms.  We  also  find 
disturbances  of  the  digestive  organs,  of  the  genito-urinary  organs, 
and  of  the  heart  and  circulation.  Also,  we  find  in  cerebral  anaemia 
that  many  visceral  diseases  are  simulated  by  this  affection. 

The  neuralgia,  before  alluded  to,  has  the  peculiarity  of  shifting  its 
seat  quite  suddenly  from  one  place  to  another,  and  this  is  one  of  the 
principal  diagnostic  features  of  spinal  anaemia.  These  neuralgic 
pains  are  increased  by  physical  or  mental  effort,  and  relieved  by 
lying  down,  when  the  contracted  and  bloodless  cerebral  and  spinal 
vessels  become  filled  with  blood.  As  a  rule,  we  do  not  find  that  our 
patients  complain  of  pain  in  the  spine.  We  more  generally  find 
that  a  sense  of  weight  and  heat  in  the  spine  is  due  to  spinal  conges- 
tion, and  not  to  anemia.  We  often  have  complaints,  as  I  have  said, 
of  nausea  and  vomiting.  We  sometimes  find  weakness,  but  no  true 
paralysis.  The  affections  of  various  parts  of  the  body  and  the  vis- 
cera, in  cerebral  and  spinal  anemia,  are  due  probably  to  the  fact  of 
the  sympathetic  system  of  nerves  being  affected.  This  system  of 
nerves,  as  it  is  well  known,  is  closely  interwoven  with  the  spinal  sys- 
tem, each  spinal  nerve  receiving  branches  from,  and  transmitting 
branches  to,  a  neighboring  sympathetic  ganglion.  The  sympathetic 
system  of  nerves  regulates  the  shortening  and  lengthening  of  all 
organic  muscular  fibres ;  it  controls  the  contraction  and  dilatation  of 
the  bloodvessels,  and  consequently  the  amount  of  blood  supplied  to 
different  parts,  and  the  rapidity  of  its  flow  through  them,  and  in  this 
way,  in  a  certain  degree,  it  regulates  the  nutrition  and  functional  ac- 
tivity of  the  organs  and  their  temperature.  It  is  also  probable  that 
the  sympathetic  system  exerts  a  direct  influence  over  the  glandular 
organs  of  the  body.  This  affords  a  rational  explanation  of  nutritive 
and  functional  difficulties  occurring  in  the  course  of  cerebral  and 
spinal  anaemia, — functions  of  different  parts  and  organs  being  im- 
paired, exalted,  or  perverted. 

Spinal  anaemia  is  a  disease  of  capillary  contraction  and  bloodless- 
ness  of  the  spine.  It  is  a  functional  disease,  and  there  are,  so  far  as 
present  knowledge  exists,  no  morbid  structural  changes.  In  making 
a  diagnosis  between  anaemia  and  other  morbid  states  of  the  spinal  cord, 
such  as  spinal  meningitis  and  spinal  congestion,  we  must  bear  in  mind 


CEREBRAL   AND    SPINAL   ANEMIA.  493 

that  in  the  latter  diseases  the  spine  is  not  tender  on  pressure.  If 
there  is  disease  of  the  vertebrae,  we  have  spinal  tenderness  ;  but  such 
disease  is  usually  found  under  the  age  of  fifteen  or  twenty  years. 
Again,  if  there  should  chance,  in  spinal  ansemia,  to  be  an  apparent 
projection  of  the  tender  vertebrae,  which  would  lead  us  to  suspect 
caries  of  the  vertebrae,  we  shall  find  that  it  is  not  a  real  projection, 
displacement,  or  curvature,  but  merely  a  simulation,  depending  on 
puffing  out  of  the  ligaments  and  investments  of  the  spine.  If  there 
were  diseased  vertebrae,  we  should  find  paralysis  of  the  lower  limbs 
in  all  probability,  while  we  almost  never  find  this  in  spinal  anaemia. 
Another  diagnostic  point  of  importance  is  the  fact  that  spinal  anse- 
mia is  relieved  by  lying  down,  while  in  spinal  congestion,  meningitis, 
and  myelitis,  the  symptoms  are  all  worse  after  a  night's  sleep.  It 
has  also  been  claimed  that  hypodermic  injections  of  strychnia  will 
relieve  spinal  anaemia,  while  they  intensify  the  symptoms  of  conges- 
tion, meningitis,  and  myelitis.  As  I  have  before  remarked,  the  pro- 
longed muscular  contractions  in  anaemia  are  painless,  while  in  mye- 
litis they  are  accompanied  with  great  suffering. 

Cerebral  anaemia  is  a  decrease  in  the  amount  of  blood  circulating 
through  the  brain  in  a  given  space  of  time,  the  dilating  and  contract- 
ing power  of  the  bloodvessels  altering  their  calibre,  and  thus  permit- 
ting a  diminution  in  the  flow  of  blood.  During  sleep,  there  is  a 
period  of  temporary  quiescence  of  the  brain,  during  which  time  it  is 
pale  and  bloodless.  Alterations  in  the  vascularity  of  the  brain  are 
due  partly  to  the  presence  of  the  cerebro-spinal  fluid,  the  brain  be- 
coming more  vascular  as  the  amount  of  the  fluid  is  diminished,  and 
as  the  vascularity  decreases,  the  bulk  of  the  fluid  increases.  As  I 
have  stated  elsewhere,  the  amount  of  blood  going  to  the  brain  is  a 
fifth  of  the  whole  bulk  of  the  blood ;  a  reduction,  therefore,  in  the 
usual  supply  of  blood  will  soon  become  apparent  in  the  cerebral  cir- 
culation. As  an  illustration  of  this,  may  be  mentioned  constant 
drains  on  the  system,  such  as  morbid  growths,  imperfect  nutrition, 
and  dyspepsia. 

Spanaemia  is  a  cause  of  cerebral  anaemia,  arising,  as  it  does,  from  mala- 
rial poisoning,  lithiasis,  and  prolonged  administration  of  certain  drugs. 
Cerebral  anaemia  may  be  produced  by  unfilled  vessels,  heart  disease, 
organic  disease  of  the  cerebral  vessels,  venous  stasis,  apoplexy,  and 
vaso-motor  disturbances  of  the  cerebral  vessels.  The  principal 
causes  of  anaemia  of  the  brain  are,  as  I  have  remarked  above,  those  that 
diminish  the  entire  amount  of  blood  in  the  brain,  such  as  haemor- 


494  PSYCHOLOGICAL    MEDICINE. 

rhage,  exudation,  and  fevers ;  the  congestion  of  the  other  organs 
of  the  body ;  the  compression  or  obstruction  of  arteries  supplying 
the  brain,  mental  excitement,  which  causes  innervation  or  spasmodic 
contraction  of  arteries ;  diminution  of  the  space  in  the  skull  by  ex- 
udations, extravasations,  or  tumors  ;  and  leucocythsemia. 

The  causes  of  spinal  ansemia  may  arise  from  congenital  predis- 
position, and  include  everything  which  tends  to  induce  a  nervous 
temperament,  and  all  things  that  tend  to  exhaust  vital  power.  Cere- 
bral ansemia  may  come  on  quite  suddenly  and  severely,  or  it  may 
come  on  slowly  and  be  less  severe.  In  cases  of  the  former  descrip- 
tion, patients  are  attacked  with  sudden  dizziness,  become  insensible 
to  impressions,  and  cannot  move.  They  faint  away,  with  slight  spas- 
modic movements.  When  the  cerebral  anaemia  comes  on  slowly, 
we  find  symptoms  of  irritation  and,  subsequently,  paralysis.  When 
the  anemia  does  not  attain  a  high  grade,  only  the  symptoms  of  cere- 
bral irritation  are  noticeable.  Sometimes  there  are  great  disturbances 
of  sensibility.  Such  patients  complain  of  much  headache  in  the  fore- 
head or  occiput,  and  sensitiveness  to  light  and  sound,  so  that  even 
daylight  admitted  into  the  room  causes  them  great  discomfort,  and 
slight  sounds  are  insupportable.  These  patients  have  flashes  before 
their  eyes,  noises  in  the  ears,  and  vertigo.  We  see  this  in  women 
with  metrorrhagia  and  other  losses  of  blood.  In  the  case  of  cere- 
bral ansemia  in  children,  we  find  that  motor  disturbances  are  most 
noticeable. 

At  times,  the  symptoms  of  cerebral  ansemia  may  be  almost  wholly 
confined  to  the  mental  functions.  The  mental  action  in  cerebral 
anaemia,  when  disturbed,  is  quick,  irritable,  and  tending  to  convulsive 
irregularities.  The  state  of  ansemia,  if  carried  beyond  a  certain  point, 
will  destroy  functional  excitability  and  the  activity  of  the  brain.  In 
cerebral  anaemia,  when  the  mental  functions  are  affected,  we  see  a 
pale  face,  cool  head,  and  weak  pulse,  the  cerebral  organs  being  in  a 
state  of  irritable  weakness,  easily  excited  by  action,  the  action,  how- 
ever, being  powerless  and  irregular.  Some  of  the  most  violent 
maniacal  attacks  I  have  ever  seen  were  in  cases  of  insanity,  when 
the  pathological  state  was  one  of  ansmia  of  the  brain.  Examination 
of  the  heart  in  these  cases  reveals  systolic  and  diastolic  bellows- 
murmurs,  heard  most  plainly  at  the  base  of  the  heart,  and  also  venous 
murmurs. 

Prognosis. — The  prognosis  in  cerebral  ansemia  and  spinal  anaemia 
is  generally  good,  if  no  organic  disease  exists;  but  if  ansemia  of  the 


CEREBRAL   AND    SPINAL   ANEMIA.  495 

brain  depends  on  diseased  vessels,  or  organic  disease  of  the  heart, 
the  prognosis  is  bad.  Cerebral  anaemia,  if  not  checked,  passes  on  to 
melancholia  and  dementia,  ending  in  psychical  torpidity  and  intel- 
lectual decay.  The  dementia  resulting  from  cerebral  anemia  begins 
in  one  of  two  ways,  either  gradually,  and  at  first  by  imperceptible 
encroachments,  or  by  maniacal  excitement.  Its  acme  is  a  mental 
state  of  profound  stupidity.  In  cases  of  dementia,  the  amount  of 
cerebral  atrophy  which  ensues  may  be  calculated  upon  by  the  enfee- 
blement  of  mental  power.  We  certainly  have  some  atrophy,  and 
this  amount  will  generally  be  found  to  correspond  with  the  degree 
of  mental  decadence  present. 

Treatment. — The  treatment  must  be  psychical  and  physical.  With 
regard  to  the  first,  as  soon  as  the  system  is  somewhat  improved, 
change  of  scene,  travelling,  and  cheerful  society  are  to  be  recom- 
mended, while  the  physical  or  medicinal  treatment  consists  in  pri- 
marily toning  up  the  system,  and  improving  both  the  quantity  and 
quality  of  blood  circulating  in  the  brain  and  spinal  cord.  If  our 
patients  are  much  debilitated,  we  must  keep  them  in  a  recumbent 
position,  and  obtain  vest  for  body  and  mind.  All  emotional  disturb- 
ances must  be  carefully  removed.  Iron,  in  combination  with  the 
chloro-phosphide  of  arsenic  (Routh's  formula),  5  minims  ter  die,  may 
be  given,  and  alcohol  must  be  freely  administered.  Old  rye  whiskey 
is  the  most  eligible  form  in  which  to  give  alcohol.  The  constant 
galvanic  current  is  a  valuable  remedy,  the  ascending  current  from 
sixteen  to  thirty  cells  being  used,  the  negative  electrode  being  placed 
at  the  base  of  the  brain,  while  the  positive  is  placed  at  the  coccyx. 
Strychnia,  in  ^Vgi'ain  doses,  is  one  of  our  most  valuable  medicines, 
and  it  may  with  advantage  be  combined  with  iron  and  quinine.  I 
have  found  a  very  eligible  and  pleasant  preparation  to  be  the  elixir 
of  the  phosphate  of  iron,  with  quinine  and  strychnia,  made  by  Wm. 
Neergaard  of  New  York.  Each  teaspoonful  contains  2  grains  of  the 
phosphate  of  iron,  i  grain  of  quinine,  and  gV  grain  of  strychnia. 
Practitioners  can  easily  combine  formulas  to  suit  themselves.  To 
lay  down  a  general  plan  of  treatment  for  cerebral  anaemia  would 
include  the  administration  of  stimulants,  tonics,  and  plenty  of  milk, 
eggs,  and  beef.  Cod-liver  oil  with  phosphorus  is  indicated.  In  cases 
of  spinal  anaemia  and  irritation,  the  first  great  means  of  cure  resides 
in  the  judicious  employment  of  counter-irritation  to  the  affected  por- 
tion of  the  spine;  and  I  have  found  the  compound  mustard  liniment, 
made  up  with  fresh  oil  of  mustard,  so  that  the  liniment  possesses  a 


49^  PSYCHOLOGICAL   MEDICINE. 

strong  pungent  odor,  applied  on  flannel  or  cotton-batting  to  the 
affected  region  of  the  spine,  and  the  whole  covered  with  oil  silk, 
the  most  efficacious  method  of  counter-irritation,  and  have  obtained 
excellent  results  from  its  use.  Blistering  the  spine  and  the  actual 
cautery  are  both  very  useful  at  times  when  indicated.  Besides  putting 
patients  suffering  from  spinal  anaemia  on  a  full  nourishing  diet,  I  am 
in  the  habit  of  prescribing  stimulants  in  liberal  doses.  In  using  the 
constant  current  of  electricity  to  the  spine,  I  apply  the  current  twice  a 
day  for  a  few  minutes  at  each  sitting.  Phosphorus  is  best  adminis- 
tered in  the  shape  of  phosphide  of  zinc,  I  think,  as  the  combination  is 
very  stable,  and  the  phosphorus  does  not  become  oxidized  as  in  other 
preparations.  -jV  ^*^  5  of  a  grain  in  pill  form  is  my  usual  dose,  which 
contains  j^  to  -5^0  of  a  grain  of  phosphorus.  Thompson's  solution  of 
phosphorus,  and  phosphorus  administered  in  cod-liver  oil,  are  both 
eligible.  From  33-  to  ^-^  of  a  grain  of  phosphorus,  thrice  daily,  is  my 
usual  dose.  The  cod-liver  oil  acts  on  the  nutrition  of  the  central 
nervous  system,  which  it  tends  to  preserve  in  its  organic  integrity, 
while  the  phosphorus  is  nerve  food  and  builds  up  the  exhausted 
nervous  system,  having  a  special  stimulating  power.  A  combination 
of  strychnia,  quinia,  and  tincture  ferri  muriat.,  with  glycerine  as  a 
menstruum,  has  given  me  good  results.  By  judicious  treatment,  and 
the  removal  of  all  causes  calculated  to  keep  up  cerebral  and  spinal 
anaemia,  we  shall  get  the  most  gratifying  results;  our  patient  will 
improve  in  personal  appearance  and  weight,  the  spinal  tenderness 
and  the  attendant  neuralgic  pains  will  disappear,  the  mental  irrita- 
bility and  pain  in  the  head  will  be  a  thing  of  the  past,  all  the  symp- 
toms will  decrease  in  intensity  and  finally  disappear,  and  a  permanent 
cure  will  be  obtained,  to  the  satisfaction  alike  of  the  physician  and 
of  the  patient. 


CHAPTER  XXVII. 

INFLAMMATORY    DISEASES    OF    THE   BRAIN    AND    ITS    MEMBRANES. 

The  periphery  of  the  brain  is  very  sensitive,  and  injuries  or  dis- 
eases of  this  portion  are  attended  with  very  serious  results.  Inflam- 
mations of  the  membranes  of  the  brain,  especially  of  the  arachnoid 
and  pia  mater,  are  consequently  very  fatal.     These  inflammations  of 


INFLAMMATORY    DISEASES    OF   THE    BRAIN   AND    ITS    MEMBRANES.      49/ 

the  membranes  of  the  brain  are  followed  by  the  formation  of  pus,  or 
the  effusion  of  serum  or  of  lymph. 

The  diagnosis  during  life  is  exceedingly  difficult  between  inflam- 
mations of  the  substance  of  the  brain,  cerebritis  or  encephalitis,  and 
that  of  the  membranes,  meningitis.  Idiopathic  cerebritis  is,  however, 
an  exceedingly  rare  disease,  and,  with  the  exception  of  cases  of  idio- 
pathic cerebritis,  caused  in  the  tropics  by  exposure  to  the  sun;  cere- 
britis from  severe  injuries,  such  as  concussion  of  the  brain;  cerebritis 
from  cranial  bone  disease,  and  that  resulting  from  the  overwhelming 
effect  of  alcohol,  of  which  I  have  seen  a  few,  we  rarely  meet  with 
cases  of  cerebritis  at  all,  except  as  secondary  to  inflammation  of  the 
membranes.*  The  effusions  of  pus,  serum,  or  lymph  in  meningitis, 
pressing  in  the  brain-substance,  produce  the  gravest  symptoms,  and 
are  fatal,  unless  relieved  by  medical  or  surgical  means.  Although 
we  very  rarely  see  the  dura  mater  affected  by  inflammation,  as  an 
idiopathic  disease,  it  may  readily  become  so  as  a  result  of  injuries  to 
the  scalp,  owing,  I  suppose,  to  an  extension,  by  sympathy,  of  inflam- 
mation of  the  pericranium,  which  is  the  external  periosteum  to  the 
dura  mater,  which  is  really  the  z;z/^r;/«/ periosteum  of  the  skull,  lying, 
as  it  does,  between  the  bony  cranium  and  the  arachnoid  membrane. 
The  anatomical  structure  of  these  membranes  is  the  same,  and  there 
is  a  very  close  relation  existing  between  them,  as  a  vascular  commu- 
nication exists  between  them  through  the  medium  of  the  cranium. 
We  find,  therefore,  that  injuries  that  affect  the  external  covering  of 
the  skull  are  often  followed  by  inflammation  of  the  dura  mater. 
Thus  a  comparatively  slight  scalp  wound  may  be  followed  by  the 
most  serious  consequences,  perhaps  of  a  fatal  nature.  I  regard, 
therefore,  all  cases  of  external  injury  to  the  head  as  of  great  impor- 
tance when  we  bear  in  mind  the  above  anatomical  relationship  be- 
tween the  pericranium  and  the  dura  mater.  The  early  symptoms 
are  not  readily  recognizable,  but  those  of  the  resulting  effusion  are 
those  indicating   compression   of  the   brain,   the  patient  becoming 

*  Dr.  Jonathan  Hutchinson,  of  England,  says  it  may  perhaps  be  doubted  whether  the 
occurrence  of  diffuse  inflammation  of  the  brain  substance  as  an  acute  disease  has  as  yet 
been  proved,  excepting  as  a  result  of  wounds.  Even  as  a  traumatic  lesion,  he  says,  its 
special  features  have  by  no  means  been  accurately  studied.  It  is,  however,  highly  prob- 
able that  after  penetrating  wounds  of  the  brain,  its  substance  may  inflame,  just  as  the 
cellular  tissue  of  a  limb  may,  the  inflammatory  processes  beginning  at  the  site  of  the 
wound  and  rapidly  spreading  through  a  large  part  of  the  hemisphere.  It  is  probably  in 
the  perivascular  spaces  that  the  process  chiefly  spreads,  and  it  is  in  these  that  the  micro- 
scope will  detect  the  most  abundant  results. 

32 


498  PSYCHOLOGICAL    MEDICINE. 

Stupid,  sleepy,  and  lethargic,  passing  into  a  state  of  coma,  from  which 
he  can  be  roused  with  difficulty,  or  not  at  all.  The  breathing  is 
heavy  and  stertorous;  the  pupils  contracted  or  dilated;  the  pulse  is 
full  and  strong  and  slow;  the  bowels  act  involuntarily;  and  retention 
of  urine  is  often  found.  If  after  even  a  slight  injury  to  the  head  our 
patient  becomes  dull,  sleepy,  and  comatose,  and  the  other  symptoms 
I  have  spoken  of,  w^e  should  suspect  effusion  on  the  surface  of  the 
dura  mater,  we  should  apply  cold  to  the  head,  open  the  bowels  by 
croton  oil  dropped  on  the  tongue,  keep  the  patient  perfectly  at  rest, 
and  exclude  light  from  his  room.  The  trephine  offers  us,  however, 
the  only  means  of  relieving  the  compression,  although  it  is  extremely 
difficult  to  determine  with  accuracy  the  exact  seat  of  the  effusion. 

In  inflammations  of  the  arachnoid  and  pia  mater,  which  are  so 
intimately  united  together  that  inflammation  in  one  necessarily  affects 
the  other,  the  effusion  of  pus  is  rare,  and  the  effusion  of  serum  very 
common,  varying  in  amount  from  an  ounce  to  two  or  three  pints. 
The  effusion  of  lymph  is  usually  found  at  the  base  of  the  brain,  about 
the  commissure  of  the  optic  nerves,  the  pons  varolii,  and  the  medulla 
oblongata,  and  we  may  also  find  it  in  large  quantities  over  the  surface 
of  the  brain,  and  running  along  the  course  of  the  fissure  of  Sylvius. 

We  have,  in  meningitis,  the  stage  of  invasion  and  the  stage  of  ef- 
fusion, but,  as  I  have  said,  the  first  stage  is  not  easy  of  diagnosis,  as 
the  symptoms  are  often  obscure. 

In  a  typical  case  we  have  rigors,  pain  in  the  head,  intolerance  of 
light  and  noise,  and  irritability  of  temper.  In  a  child,  the  attack 
may  begin  with  a  violent  scream  or  cry,  and  the  head  is  tossed  around 
in  every  direction.  The  heat  of  the  head  is  increased,  and  the  tem- 
perature considerably  increased.  The  skin  is  hot  and  dry  and  the 
pulse  quick  and  strong.  The  urine  is  scanty  and  high-colored,  and 
the  bowels  either  constipated,  or,  if  open,  the  stools  are  pale  in  color 
and  offensive.  The  two  most  marked  symptoms,  and  those  on  which 
I  would  lay  special  stress,  are  the  existence  of  contracted  pupils  and 
vomiting.  If  these  two  symptoms  co-exist,  the  diagnosis  is  certain 
when  the  other  symptoms  I  have  enumerated  are  present.  These 
are  the  symptoms  of  the  first  stage  of  meningitis.  In  the  secondary 
stage,  or  stage  of  effusion,  our  patient  falls  into  a  comatose  and  le- 
thargic condition,  with  a  full,  slow  pulse,  and  dilated  pupils — the 
latter  symptom  indicative  of  effusion.  We  may  have  squinting,  con- 
vulsions, rigidity  of  one  extremity,  perhaps,  involuntar)''  discharge 
of  faeces  and  urine,  jactitation,  and  finally  death.     Sometimes,  in  spite 


INFLAMMATORY   DISEASES    OF   THE    BRAIN    AND    ITS    MEMBRANES.      499 

of  the  most  desperate  symptoms,  we  shall  get  a  cure,  if  we  treat  our 
patient  skilfully,  and  with  due  regard  to  his  diathesis. 

We  must  direct  our  treatment  to  the  constitutional  taint.  Thus,  if 
we  are  treating  a  rheumatic  patient,  we  should  give  him  colchicum 
and  salicylic  acid.  If  he  is  scrofulous,  we  should  give  him  cod-liver 
oil  and  iron,  and  if  syphilitic,  the  iodide  of  sodium  or  potassium  and 
mercury.  In  other  cases,  antiphlogistic  treatment,  calomel  in  re- 
peated doses  with  saline  purgatives,  and  early  bloodletting,  if  it  Is 
decided  to  bleed  at  all,  at  the  very  outset  of  the  symptoms. 

In  children,  we  may  put  leeches  on  the  temples  and  a  bladder  of 
ice  on  the  head,  open  the  bowels  by  salines,  and  give  calomel  in  re- 
peated doses,  which  will  result,  I  think,  in  positive  benefit.  In  the 
stage  of  effusion,  with  dilated  pupils  and  coma,  although  the  patient 
will  probably  die,  we  may  blister  the  back  of  the  neck  to  promote 
absorption  of  the  effused  fluids,  calomel  in  grain-doses  for  some 
time,  and  the  iodide  of  sodium  or  potassium  five-grain  doses  three 
times  a  day,  and  we  may  possibly  save  our  patient. 

Typhoid  fever,  as  it  is  well  known,  presents  very  often  at  its  outset 
the  most  marked  cerebral  symptoms,  and  is  liable,  perhaps,  in  some 
cases,  to  be  mistaken  for  inflammation  of  the  substance  of  the  brain, 
or  cerebritis.  We  may  be  called  to  see  patients  who  may  present 
most  of  the  symptoms  belonging  to  inflammation  of  the  brain,  namely, 
hot  head,  violent  delirium,  hot  skin,  full  and  rapid  pulse,  great  thirst, 
and  furred  tongue,  but,  on  very  careful  examination  of  the  body,  we 
may  detect  one  or  two  of  the  characteristic  rose  spots  which  will  en- 
able us  to  pronounce  the  case  one  of  typhoid  fever,  and  to  give  a 
favorable  prognosis.  It  is  often  very  difficult  to  detect  typhoid  fever, 
for  the  rose  rash  is  apt,  I  think,  to  be  very  scanty,  perhaps  limited  to 
one  or  two  spots,  and  these  attacks  are  likely  to  prove  the  most  se- 
vere. I  perhaps  have  spoken  too  hastily  when  I  say  we  can  give  a 
favorable  prognosis  in  these  cases,  for  the  presence,  as  I  have  just 
said,  of  a  very  few  rose  spots  indicates  an  attack  of  great  severity, 
and  death  sometimes  rapidly  ensues  in  these  attacks. 

Respecting  delirium  tremens,  we  must  diagnose  between  this  dis- 
ease of  debility  and  inflammation  of  the  brain.  The  head  in  delirium 
tremens,  instead  of  being  hot  and  dry,  is  cool  and  moist,  and  the  skin 
bathed  in  perspiration.  The  delirium,  instead  of  being  furious,  is 
low  and  suspicious  ;  the  tongue,  instead  of  being  dry,  is  coated  with 
a  moist,  creamy  fur,  and,  if  death  ensues,  there  is  very  likely  nothing 


500  PSYCHOLOGICAL    MEDICINE. 

visible  in  the  inter-cranial  structures.  While  we  treat  an  inflamma- 
tion of  the  brain  by  ice  to  the  head,  leeches,  by  low  diet,  calomel, 
and  purgatives,  we,  on  the  other  hand,  treat  delirium  tremens  by  an 
entirely  different  plan — by  nourishment,  perhaps  by  stimulants,  sed- 
atives, and  careful  watching  and  nursing. 

In  acute  mania,  the  inflammatory  symptoms  of  cerebritis  are  want- 
ing, and  the  existence  of  a  furious  delirium  is  the  only  thing  in  com- 
mon in  the  two  diseases.  In  the  inflammation  of  the  brain,  or  cere- 
britis attending  concussion  of  the  brain,  in  which  the  whole  brain  is 
very  much  shaken,  capillary  congestion  takes  places,  and  the  inflam- 
matory process  passes  on  to  its  destructive  stages.  In  these  cases, 
about  forty-eight  hours  after  the  receipt  of  the  injury,  vomiting  oc- 
curs, severe  pain  in  the  head,  the  pupils  are  contracted,  the  scalp  is 
hot,  there  is  intolerance  of  light  and  noise,  the  pulse  is  full,  hard, 
and  strong,  and  we  have  a  violent  delirium. 

In  inflammation  of  the  brain  from  disease  of  the  cranial  bones,  of 
which  I  have  spoken,  we  find  a  young  person,  probably  of  a  stru- 
mous diathesis,  who  very  likely  has  had,  for  a  long  time,  a  discharge 
from  the  ear,  suddenly  seized  with  a  pain  in  the  head,  vomiting,  de- 
lirium, contracted  pupils,  hot  skin,  loaded  tongue,  and  the  other 
symptoms  of  cerebritis,  and  this  is  a  very  fatal  form  of  the  disease. 
The  treatment  of  these  latter  cases  is  very  unsatisfactory,  but  where 
there  is  a  discharge  from  the  ear,  we  should  encourage  the  discharge, 
apply  blisters  behind  the  ear,  and  employ  a  mild  antiphlogistic  plan 
of  treatment. 

When  the  cerebritis  is  the  result  of  the  immediate  effects  of  alco- 
hol, if  our  patient  has  a  hot  head,  furious  delirium,  bloodshot  eyes, 
we  are,  I  think,  in  some  cases,  perfectly  justified  in  abstracting  blood, 
but  never  where,  as  in  delirium  tremens,  which  is  not  an  inflammatory 
disease,  our  patient  is  broken  down  by  previous  excesses.  Ice  to 
the  head,  and  saline  aperients  and  tranquillizing  measures  are  also 
necessary  in  these  cases. 


NEURALGIA.  50I 


CHAPTER  XXVIII. 


NEURALGIA. 


I  THINK  the  nervous  pain,  resulting  from  a  morbid  exaltation  of 
sensibility,  which  is  to-day  affecting  so  many  people,  and  particularly 
so  many  American  women,  is,  perhaps,  in  its  treatment,  and  sometimes, 
also,  in  its  diagnosis,  very  troublesome  to  the  general  practitioner. 
These  nervous  pains  may  simulate  very  serious  organic  trouble,  and 
I  have  been  consulted  by  more  than  one  able  physician,  who  thought 
that  he  was  suffering  from  organic  brain,  or  spinal  cord  disease,  when 
really  a  nervous  prostration  had  been  the  cause  merely  of  an  invet- 
erate neuralgia  of  great  intensity,  and  where  rest,  change  of  scene, 
nervines  and  the  constant  current  of  electricity  accomplished  a  speedy 
cure.  In  neuralgia,  sensibility  is  both  perverted  and  exalted.  There 
is  no  inflammation,  no  fever,  but  the  severity  of  the  pain  may  be  in- 
tense. The  irritation  causing  neuralgia  may  be  located  in  the 
brain,  in  the  spinal  cord,  or  in  the  trunk  of  the  nerve  that  supplies  the 
affected  part,  i.  e.,  in  the  sentient  extremity  of  a  nerve-trunk.  An 
aneurism  of  the  femoral  artery  has  given  rise  to  excruciating  pain  in 
the  knee,  and  I  have  seen  numerous  instances  since  the  late  war, 
where  musket-ball  wounds  have  healed  nicely,  but  have  left  very  se- 
vere neuralgia  in  the  extremities.  In  neuralgia  of  the  extremities, 
therefore,  we  should  search  for  trouble  or  injury  to  the  trunk  of  the 
nerve,  whose  sentient  extremities  are  affected,  and,  if  we  then  find  no 
source  of  irritation,  we  may  suspect  the  spinal  cord  or  brain  as  the 
seat  of  irritation.  The  violent  pains  of  neuralgia  are  situated  either 
in  the  trunk  or  branch  of  a  nerve,  and  occur  in  paroxysms  of  irreg- 
ular duration,  and  at  either  regular  or  irregular  intervals.  Among 
the  most  intense  neuralgias  may  be  mentioned  tic  douloureux  or  fa- 
cial neuralgia,  affecting  the  facial  branches  of  the  fifth  pair  of  nerves. 
In  this  form  of  neuralgia,  the  patient  will  writhe  with  the  agonizing 
pain  in  the  side  of  the  face,  beginning  near  the  eye  or  ear,  the  pain 
being  of  an  acute,  stabbing,  lacerating  character,  and  darting  like  an 
electric  shock  into  the  upper  and  lower  jaw,  lips,  eye,  forehead,  and 
scalp,  and  a  strong  light,  a  loud  noise,  a  draught  of  air,  or  a  mental 
emotion — all  tend  to  aggravate  this  most  intolerable  disorder.  We 
have  to  soothe  the  over-excited,  central,  nervous  apparatus,  and  ex- 
amine for  impairment  of  the  digestive,  assimilating  and  excreting 


502  PSYCHOLOGICAL    MEDICINE. 

functions.  There  are  no  structural  changes  to  be  found  in  the  tri- 
facial nerve  or  its  ramifications,  the  ophthalmic,  superior  maxillary,  or 
inferior  maxillary  branches  of  the  fifth  pair  of  nerves.  The  infra-orbi- 
tal branch  is  the  one  I  have  generally  found  to  be  the  oftenest  af- 
fected as  it  passes  from  the  foramen,  the  pain  starting  and  radiating 
from  this  point  on  the  cheek  of  the  patient.  All  the  cranial  nerves 
may  be,  and  are,  peculiarly  susceptible  to  neuralgia :  the  olfactory 
nerves,  the  exit  of  which  is  the  cribriform  plate  ;  the  optic  nerves,  the 
exit  of  which  is  the  optic  foramen ;  the  motor  oculi,  the  exit  of 
which  is  the  foramen  lacerum  anterior ;  the  trochlearis,  having  the 
same  exit;  the  ophthalmic  branch  of  the  fifth  pair  of  nerves,  having 
the  same  exit ;  the  superior  maxillary  branch  of  the  fifth  pair,  the  exit 
of  which  is  the  foramen  rotundum ;  the  inferior  maxillary  branch  of 
the  fifth  pair,  the  exit  of  which  is  the  foramen  ovale ;  the  sixth  pair — ab- 
ducens — of  which  the  exit  is  the  foramen  lacerum  anterior ;  the  seventh 
pair — facial  nerves — the  exit  of  which  is  the  meatus  auditorium  in- 
ternum ;  the  eighth  pair — auditory  nerves — the  exit  of  which  is  the 
same  as  the  seventh  pair;  the  ninth  pair,  glosso-pharangeal,  the  exit 
of  which  is  the  foramen  lacerum  post;  the  pneumogastric,  or  par 
vagum,  the  exit  of  which  is  the  same,  as  also  it  is  of  the  eleventh 
pair  of  cranial  nerves,  the  spinal  accessory;  and,  lastly,  the  hypo- 
glossal nerves,  or  twelfth  pair,  the  exit  of  which  is  the  anterior  con- 
dyloid foramen.  The  neuralgic  pain  varies  in  character,  is  always 
excessive,  and  returns  at  irregular  periods.  It  may  be  related  to 
functional  disturbance  or  irritation  of  the  Gasserian  ganglion,  which 
we  must  soothe  by  Duquesnel's  aconitia  in  g-g- ^-gr^in  doses,  and  feed 
by  cod-liver  oil  in  small  doses,  as  the  nerve-cells  of  the  whole  central 
nervous  system  have  to  be  fed  in  neuralgias.  We  should  bear  in 
mind  that  if  we  find  redness,  heat,  or  swelling  of  an  affected  part,  we 
have  to  deal  with  a  7ie2iritis,  not  a  neuralgia.  Thus  the  pressure  of 
a  gravid  uterus,  in  a  patient  recently  under  my  care,  produced  a 
pressure  on  the  pelvic  nerves,  principally  in  the  sciatic,  occasioning 
acute  lancinating  pain  and  partial  paralysis.  It  was  a  case  of  puer- 
peral neuritis,  of  extreme  intensity,  and  the  first  severe  case  I  had 
ever  met  with.  There  was  a  fixed  pain,  tension,  swelling,  and  ten- 
derness on  pressure,  and  the  pain  increased  when  the  muscles  sup- 
plied by  the  sciatic  were  contracted.  In  the  neuromata,  or  nerve- 
tumors,  we  may  find  a  chronic  neuritis.  These  tumors  are  formed 
on  nerve-trunks,  or  branches,  and  vary  in  size  from  the  size  of  a  pea 
to  that  of  an  egg,  and  these  tumors  may  be  multiple.     They  are  hard 


NEURALGIA.  5O3 

and  firm  to  the  touch,  very  painful  on  pressure,  and  the  pain  extends 
to  the  peripheral  terminations  of  the  affected  nerve.  These  cases 
may  be  treated  by  small  blisters  in  the  affected  course  of  the  nerve, 
by  anodyne  fomentations,  and  by  the  constant  current  of  electricity, 
and  internally  by  anodynes  and  alteratives. 

Extirpation  of  the  tumor  becomes  advisable  in  a  certain  class  of 
cases.  If  in  the  neuralgias  other  treatment  fails,  and  our  patient  has 
a  furred  tongue  and  loaded  bowels,  and  no  appetite,  an  alkaline 
course  of  treatment  and  purgatives  may  sometimes  accomplish  a  cure, 
and  we  must  treat  the  diathesis  of  the  patient.  Among  the  neuralgias 
may  be  enumerated  gastrodynia,  angina  pectoris,  neuralgia  of  the 
kidneys  or  nephralgia,  hemicrania,  sciatica,  visceral  neuralgias,  and 
intercostal  neuralgia.  I  have  recently  seen  rather  an  unusual  case 
of  intercostal  neuralgia,  in  a  lady  about  fifty  years  of  age,  in  whom  I 
found  both  disordered  digestion  and  very  marked  spinal  irritation. 
The  pain,  which  was  located  in  the  ninth  intercostal  space,  was  in- 
creased by  a  full  inspiration  and  by  coughing.  It  also  extended  to 
the  spine  and  was  sharp  and  darting.  This  lady  had  suffered  from 
repeated  attacks  of  great  severity,  which  had  uniformly  been  treated 
with  opium  and  without  success.  I  found  this  patient's  tongue  heavily 
coated,  a  foul  breath  and  constipated  bowels,  and  very  marked  ten- 
derness on  pressure  in  the  dorsal  region  of  the  spine.  I  accordingly 
suggested  a  plan  of  treatment  consisting  of  rhubarb  and  soda,  made 
palatable  by  the  addition  of  cinnamon  and  sugar;  also  the  application 
to  the  tender  spots  in  the  spine  of  the  compound  mustard  liniment, 
made  up  with  the  freshly  prepared  oil  of  mustard,  to  be  applied  on 
a  small  folded  piece  of  absorbent  lint,  to  be  covered  with  oiled  silk, 
and  this  to  be  repeated  every  night;  also  cod-liver  oil  in  teaspoonful 
doses,  and  a  tonic  mixture  containing  strychnia  in  -^-grain  doses ; 
also  electricity  in  the  form  of  central  galvanization.  I  am  informed 
that  this  plan  of  treatment  resulted  in  a  rapid  cure.  Phosphorus  and 
cod-liver  oil,  in  such  cases,  together  with  electricity,  should  be  em- 
ployed for  months  to  restore  the  impaired  nutrition  of  the  central 
nervous  system.  In  sciatica,  which  is  most  frequent  in  wet  and 
stormy  weather,  we  find  intense  pain  in  the  course  of  the  sciatic 
nerve,  generally  downward  along  the  posterior  surface  of  the  thigh 
to  the  popliteal  space,  and  very  frequently  extending  down  the  tibial 
nerve.  It  is  generally  worse  at  night,  and  there  are  remissions  more 
or  less  complete  in  character.  We  may  have  partial  paralysis  of  a 
limb,  with  emaciation,  and  also  dfagging  of  a  limb.     In  addition  to 


504  PSYCHOLOGICAL    MEDICINE. 

correcting  any  disordered  state  of  the  digestive  organs,  and  building 
up  the  general  health,  we  may  employ  a  series  of  small  fly  blisters, 
use  deep  hypodermics  of  morphia  and  atropia,  apply  ice  on  the 
affected  part  or  a  cold  douche  over  the  hip  and  leg,  a  solution  locally 
of  cyanide  of  potassium,  5j  to  ovi  of  water,  applied  by  friction  on  the 
course  of  the  nerve,  or,  finally,  the  constant  current  of  electricity. 
The  hypodermic  injection  of  atropia  in  one  injection  of  j^-  of  a  grain, 
which  will  cause  some  delirium,  has  cured  entirely  some  cases  that 
had  resisted  all  other  treatment.  In  lumbago,  allied  to  neuralgia, 
the  inhalation  of  ether  will  afford  great  relief  In  the  visceral  neu- 
ralgias, especially  of  the  uterus  and  ovaries,  the  hypodermic  use  of 
atropia  is  decidedly  the  most  efficacious  mode  of  treatment  at  our 
command,  using  from  y^ir  to  ^-^  of  a  grain  according  to  circumstances. 
Also  the  constant  current  of  electricity  locally  over  the  hypogastric 
region,  or  locally  as  the  circumstances  of  the  case  may  dictate.  In 
neuralgia  of  the  stomach  there  is  nothing  at  all  comparable  to  a 
combination  of  bismuth,  carbonate  of  iron  and  morphia  in  powder, 
administered  three  times  a  day.  In  angina  pectoris  the  nitrate  of 
amyl,  or  nitro-glycerine  pills,  are  indicated.  In  hemicrania,  a  neu- 
ralgic headache  of  one  side  of  the  head,  when  periodical,  as  it  often 
is,  a  course  of  Fowler's  solution,  with  laxatives,  will  accomplish  a 
cure,  as  will  also  quinine,  in  many  instances,  when  malaria  is  the 
cause,  as  very  frequently  is  the  case.  In  cases  where  hemicrania  is 
not  strictly  periodical,  I  regard  as  by  far  the  most  valuable  remedy 
cannabis  indica  in  full  doses.  In  the  forms  of  visceral  neuralgia,  met 
with  in  hypochondriacal  or  hysterical  cases,  we  must  combat  the 
asthenic  condition  usually  existing  by  iron,  quinine,  and  strychnia, 
or  arsenic,  and  quiet  the  morbid  exalted  sensibility  by  a  course  of 
warm  baths;  a  course  of  electricity  is  also  of  value  in  these  cases.* 

The  pathology  of  neuralgia  consists  in  the  functional  impairment 
of  the  sensory  nerve-cells  of  the  central  sensory  tract  of  the  nervous 
system,  which  is  the  seat  of  nervous  sensibility,  which  functional 
disease  consists  of  a  worn,  irritable,  and  hypersensitive  condition,  as 
Professor  J.  S.  Jewell  has  ably  demonstrated.  The  nutrition  of  the 
cortex  of  the  brain  is  at  fault,  and  there  is  often  an  anaemic  state  of 
the  brain  and  cord  to  be  combated.  Neuralgic  pain  may  doubtless, 
in  some  instances,  be  dependent  upon  peripheral  vaso-motor  disturb- 
ance, but  the  nerve-centres  are  generally  the  seat  of  the  disease,  and 
the  lesion  a  lesion  of  nutrition.     I  regard  the  most  important  pre- 

*  The  galvanic  current  and  static  electricity  are  here  indicated. 


NEURALGIA.  505 

disposing  cause  of  neuralgia  to  be  neurasthenia,  or  nervous  exhaus- 
tion, which,  by  impairing  and  lowering  vitality,  inducing  an  irritable 
state  of  the  brain,  causing  sleeplessness  and  getting  up  a  general 
asthenic  state  of  the  whole  system,  predisposes  directly  to  neuralgia, 
by  inducing  the  very  lesions  of  nutrition  in  the  brain,  which  I  have 
just  been  speaking  of  We  find,  as  the  result  of  excessive  mental 
labor,  anxiety,  depressing  mental  emotions,  hsemorrhages,  and  sleep-^ 
lessness,  a  state  of  things  which,  in  women,  is  associated  with  uterine 
displacements  and  spinal  irritation,  and,  in  men,  by  irritability,  mental 
depression,  and  impending  mental  disorder.  Malaria  may  also  de- 
velop an  extensive  state  of  nervous  exhaustion,  exhibiting  almost  an 
incredible  number  of  nervous  phenomena.  Professor  Austin  Flint, 
in  his  able  writings  on  the  periodical  fevers,  has  very  correctly, 
according  to  my  experience  in  nervous  diseases,  pointed  out  that 
paroxysms  of  neuralgia  will  at  times  seem  to  take  the  place  of  the 
paroxysms  of  intermittent  fever,  recurring  with  the  same  regularity 
after  intervals  corresponding  to  those  in  the  different  types  of  inter- 
mittent fever,  and  a  cure  is  effected  by  quinia  or  arsenic,  which 
destroys  the  morbific  agent,  the  cryptogamic  vegetable  organisms, 
which  causes  the  malaria.  For  the  general  nervousness  resulting 
from  malaria,  there  is  no  known  remedy  comparable  to  arsenic.  Too 
early  educational  pressure  also  operates  in  the  production,  as  the 
child  grows  up,  of  exhaustive  nervous  neuralgia.  The  loss  of  nerve- 
tone  in  neurasthenia,  or  nerve  exhaustion,  affects  the  kidneys,  and 
we  often  get  obscure  attacks  of  drowsiness  as  the  result  of  deranged 
functional  action  of  the  kidneys  and  great  excess  of  urea.  As  a 
result  of  nervous  exhaustion,  cerebral  hyperaemia  and  anaemia  may 
follow  with  their  symptoms  ;  profuse  perspirations  also  accompany 
marked  nervous  exhaustion,  and  the  natural  elasticity  of  the  skin  is 
lost.  These  cases  of  nervous  exhaustion,  or  neurasthenia,  furnish  a 
great  many  cases  of  neuralgia,  as  a  result  of  the  impaired  nutrition, 
and  therefore  I  have  classed  neurasthenia,  or  nerve  exhaustion,  as  the 
first  great  predisposing  cause.  There  is  one  point  of  great  importance 
to  be  spoken  of  here,  and  that  is,  that  the  tendency  of  neurasthenia 
is  toward  incipient  insanity,  and  that  if  the  physician  notices  in  his 
patient,  suffering  from  nervous  exhaustion,  mental  depression  and 
insomnia,  and  wishes  to  prevent  active  insanity  taking  the  form  of 
melancholia  or  mania,  he  must  at  once  prohibit  any  further  mental 
work,  and  prescribe  a  change  of  air  and  scene  for  his  patient,  taking 
him  altogether  away  from  business  cares  and  anxieties  for  at  least 


506  PSYCHOLOGICAL   MEDICINE. 

one  month.  Constant  change  of  scene,  as  in  travel,  tires  and  exhausts 
rather  than  rests  our  patient  with  nervous  exhaustion,  and  rest  and 
nutrition  are  the  two  cardinal  points  in  treatment,  with  quinine  and 
arsenic  as  nerve-tonics,  together  with  a  course  of  electricity.  The 
motor  phenomena  in  these  cases  consist  in  a  loss  of  muscular  power 
and  endurance.  The  circulation  is  also  affected  by  exaltation  of 
vaso-motor  reflex  excitability,  so  that  palpitations  occur,  as  the  result 
of  disturbed  action  of  the  heart.  The  vaso  constrictors  and  the  vaso- 
dilators, the  two  kinds  of  nerve-fibres  connecting  the  peripheral  vaso- 
motor mechanisms  with  the  spinal  cord  and  medulla,  are  also  affected 
in  a  reflex  way  in  nervous  asthenia,  causing  circulatory  disturbances, 
varying  in  extent  and  degree.  The  disturbances  in  secretions,  to 
which  I  have  alluded,  are  evidence  of  disturbance  of  the  secreto-motor 
part  of  the  nervous  apparatus.  There  is  inabilit}'  to  sustain  prolonged 
mental  effort,  and  the  memory  is  defective.  This  is  all  indicative  of 
brain-fatigue  or  brain-waste,  and  in  these  states  the  chloro -phosphide 
of  arsenic  will  give  good  results  if  used  for  some  weeks  judiciously. 
I  prefer  beginning  with  5  minims  of  the  chloro-phosphide  (Routh's 
formula)  thrice  daily  after  meals,  and  gradually  decrease  it  until  2 
minims  are  taken  thrice  daily,  and  order  this  continued  for  some 
time,  and  finally  drop  the  arsenic  altogether.  At  the  end  of  about 
six  weeks  of  arsenical  treatment,  the  patient  experiences  a  general 
sense  of  well-being,  the  elasticity  of  the  skin  returns,  and  the  physical 
and  mental  tone  returns. 

These  cases  all  give  the  same  history  of  being  unable  to  do  or  en- 
dure, either  mentally  or  physically,  what  they  did  in  health  ;  and 
also  that  they  are  much  more  easily  affected  than  when  in  health. 
They  will  also,  very  often  complain  of  irregular  action  of  the  heart ; 
and  a  general  diminution  of  vascular  tonus  makes  them  complain  of 
vertigo,  dimness  of  vision,  and  even  syncope,  from  a  change  of 
position,  such  as  getting  out  of  bed  to  a  standing  position.  We 
may  also  see,  in  asthenic  cases,  certain  morbid  psychical  symptoms, 
distnist  being  one  of  the  most  prominent,  and  perhaps  even  gravest 
psychical  symptoms.  I  have  been  thus  explicit  in  my  remarks 
on  nervous  exhaustion  because  very  often,  to  cure  neuralgia,  you 
must  first  remove  this  influential  predisposing  cause.  It  was  Rom- 
berg, I  think,  who  defined  neuralgia  as  the  "  prayer  of  a  nerve  for 
healthy  blood,"  and  it  is  a  very  good  definition. 

Finally,  among  the  remedial  agents  to  be  used  in  neuralgia,  we 
may  enumerate  cod-liver  oil  and  the  whole  series  of  animal  fats, 


NEURALGIA.  50/ 

Thompson's  solution  of  phosphorus,  Duquesnel's  aconitia,  commenc- 
ing with  one-two-hundreth-grain  doses,  and  carefully  increasing  until 
physiological  effects  are  produced,  arsenic,  quinine,  gelsemium,  can- 
nabis indica,  the  cautery,  the  galvanic  or  constant  current  of  electricity, 
and  the  hypodermic  use  of  morphia  and  atropia. 

By  judicious  treatment,  even  in  the  worst  cases  of  facial  neuralgia, 
we  may  accomplish  perfect  cures  by  carefully  studying  each  indi- 
vidual case  as  it  presents  itself  for  treatment,  and  noting  the  patho- 
logical causes  and  associations  of  neuralgia.  Thus,  a  cerebro-spinal 
neuralgia  may  depend  upon  inflammatory  action  in  a  limited  portion 
of  the  cord  or  of  the  theca  vertebralis.  We  may  see  intense  neural- 
gia with  caries  of  the  spine ;  also  in  the  spinal  nerve,  situated  at  the 
seat  of  the  disease.  The  neuralgia  caused  by  carious  teeth,  and  caries 
and  exfoliation  of  bone,  will  cease  upon  the  removal  of  the  cause. 

I  have  met  with  many  cases  of  severe  visceral  neuralgias  where 
the  trouble  was  evidently  local  and  not  the  effect  of  a  pre-existing 
morbid  condition  of  the  central  nervous  system,  as  in  haemorrhoids, 
impacted  faeces,  and  affections  of  the  urinary  organs,  when,  upon  the 
removal  of  the  pathological  cause,  the  neuralgia  disappeared  and 
did  not  return.  I  have  seen  violent  malarial  neuralgias  completely 
cured  by  a  single  twenty-grain  dose  of  quinine  after  a  purgative  had 
been  administered. 

Tumors  of  the  brain,  ossific  deposits  in  the  pia  mater  and  near  the 
base  of  the  brain,  exostoses  and  caries  of  the  cranial  bones,  are  all 
pathological  causes  of  inveterate  protracted  neuralgia.  The  pain  in 
these  cases  is  dependent  upon  irritation  of  a  portion  of  the  trunk  or 
ramifications  of  the  affected  nerve.  I  have  a  case  at  present  under 
observation  where  the  neuralgia,  which  is  very  severe,  is  dependent 
upon  disease  of  the  jaw.  The  exostoses,  when  they  are  the  patho- 
logical cause  of  neuralgia,  are  situated  in  the  frontal  sinuses,  or  in  the 
ethmoidal  or  sphenoidal  bones,  or  on  the  roots  of  a  tooth.  Superfi- 
cial injuries,  punctures,  or  cicatrices  have  also  often  occasioned  neu- 
ralgia of  a  severe  type.  Sudden  and  forcible  extension  of  nerves  by 
tumors,  aneurisms,  or  dislocations  are  also  causes  of  neuralgia. 
Also  contusions  of  the  nerves  may  cause  severe  neuralgias ;  punctures 
of  the  nerves  occasion  often  terrible  neuralgia,  lasting  long  after  the 
injury,  and  associated  with  tremors  and  even  convulsions  of  the  mus- 
cle supplied  by  the  injured  nerve. 

The  fibrous  enlargement  which  is  left  after  the  inflammation  has 
subsided  may  give  rise  to  the  most  serious  neuralgia,  which  nothing 


508  PSYCHOLOGICAL   MEDICINE. 

but  division  of  the  nerve  will  relieve.  If  a  nerve  becomes  involved 
in  the  cicatrix  of  a  wound  or  burn,  severe  neuralgia  will  result;  also 
if  a  nerve  be  severed  by  an  injury. 

Chloroform  is  one  of  the  most  valuable  topical  irritants  in  neural- 
gia that  we  possess,  and  the  profession  is  probably  familiar  with  M. 
Brown-Sequard's  conclusion  recently  advanced,  "  That  chloroform 
applied  to  the  skin  of  an  animal  produces  a  local  anaesthesia  without 
passing  through  the  circulatory  system."  It  must  be  applied  so  as 
to  intensely  irritate  the  extremities  of  the  peripheral  cutaneous  nerves, 
and  even  in  the  severe  pains  of  locomotor  ataxy,  through  the  rela- 
tions of  the  peripheral  sensitive  nerves  with  the  posterior  spinal  roots, 
it  alleviates  these  pains  very  markedly.  The  treatment  of  neuralgic 
pains  by  mechanical  vibrations  is  of  much  interest  now,  being  ad- 
vanced by  Dr.  Vigoroux,  of  France ;  and  from  my  own  experience 
with  localized  faradization,  irritating  the  skin  by  the  mechanical 
vibrations  of  the  induced  current  of  electricity  in  cases  of  sciatica 
and  locomotor  ataxia,  I  can  partially  confirm  his  theor}^  as  a  practi- 
cal one.  I  have  certainly  seen  rapid  relief  of  pain  by  such  peripheral 
irritation.  The  galvanic  current  also  relieves  pain  by  its  revulsive 
effect  when  other  agents  have  proved  ineffectual.  Dr.  Vigoroux's 
experiments  in  treating  and  relieving  pain  by  the  vibrations  of  the 
tuning-fork,  causing  an  anaesthesia  in  recurrent  neuralgias,  I  have 
not  yet  employed.  Dr.  Vigoroux  claims  that  the  vibrations  of  the 
tuning-fork  have  the  same  physiological  action  in  alleviating  pain  as 
has  electricity.  The  action  of  the  vibrations  is  localized  by  arming 
the  terminal  point  of  the  tuning-fork  with  a  wooden  button,  which 
is  applied  over  the  nerve  which  is  the  seat  of  pain,  the  terminal  disc 
not  to  be  of  a  diameter  exceeding  one  centimetre.  The  effects  are 
said  to  be  the  most  rapid  when  the  applications  are  over  a  sensitive 
nerve-plexus.  When  applied  near  the  foramina,  where  the  branches 
of  the  fifth  pair  of  nerves  pass  out,  the  relief  from  the  pain  is  rapid. 
Also  in  hemicrania  or  migraine,  when  the  vibrations  were  communi- 
cated to  the  cranial  walls  rapidly,  the  pain  was  quickly  relieved.  I 
have  no  doubt  at  all  of  the  truth  of  these  statements,  as  they  accord 
entirely  with  my  own  series  of  experiments  with  the  induced  or 
magnetic  current  of  electricity  for  the  relief  of  facial  neuralgia  and 
migraine.  In  my  experiments  I  have  not  found  that  the  rapidity  of 
the  vibrations  seemed  to  matter  much,  local  anaesthesia  and  analge- 
sia being  produced  in  typical  cases  of  neuralgia  of  the  fifth  pair  of 
nerves,  and  also  in  migraine,  in  both  instances. 


NEURALGIA. 


509 


In  concluding  this  article  on  neuralgia,  I  wish  to  allude  to  nerve- 
stretching  for  the  relief  of  the  neuralgic  pain  in  locomotor  ataxy. 
The  nerve  should  be  reached  by  an  incision  two  and  a  half  inches 
long;  a  grooved  director,  with  the  convexity  upward,  is  then  to  be 
passed  under  the  nerve  to  be  stretched,  and  then,  by  grasping  the 
two  ends  of  the  director,  traction  may  be  made  on  a  line  perpen- 
dicular to  the  axis  of  the  nerve,  with  sufficient  force  to  lift  it  about 
two  inches.  There  is  no  danger  of  injuring  the  nerve  by  this  opera- 
tion, which  I  propose  to  have  performed,  in  all  cases  of  mine  here- 
after, whenever  necessary  to  relieve  the  "  lightning  "  pains  of  loco- 
motor ataxy.  The  sciatic,  crural,  median,  and  radial  nerves  may  all, 
I  think,  be  very  advantageously  stretched  in  these  cases,  not  only 
with  great  relief  to  pain,  but  with  great  improvement  to  incoordina- 
tion ;  and,  I  think,  this  comparatively  new  operation  will  have  great 
success  in  the  hands  of  skilful  operators. 

Professor  Erb,  of  Heidelberg,  in  writing  on  the  diagnosis  and 
treatment  of  neuralgia,  speaks  as  follows  respecting  electricity  as  a 
therapeutic  agent  in  the  treatment  of  neuralgia,  and  my  own  experi- 
ence certainly  confirms  the  truth  of  his  statement : 

Electricity  has  recently  become  the  most  important  remedy  in  the  treatment  of  neural- 
gia in  consequence  of  the  brilliant  success  that  has  attended  its  application  in  many  dif- 
ferent forms  of  the  disease,  and  in  no  other  disease  are  the  results  of  electro-therapeutical 
treatment  so  certainly  established  as  in  neuralgia.  Of  the  two  kinds  of  electricity  now 
in  constant  use,  the  galvanic  current  (continuous  current)  is  found  to  be  the  more  active 
and  applicable  to  a  greater  variety  of  forms  of  disease  than  faradic  electricity.  Faradic 
electricity  (the  interrupted  current)  is  chiefly  useful  in  peripheric  neuralgia,  when  the* 
nerves  can  be  reached  by  the  current,  and  in  cases  where  no  remarkable  anatomical 
change,  as  neuritis  or  the  like  is  present,  and  thus  especially  in  the  so-called  purely  idio- 
pathic or  "  habitual  "  neuralgia. 

The  galvanic  current  has  at  least  the  same  action  upon  peripheric  neuralgia,  whilst, 
in  addition,  it  is  very  effective  in  the  central  and  deep-seated  forms  of  the  disease  (cere- 
bral and  spinal  neuralgias  and  neuralgia  of  the  roots  of  nerves).  Moreover,  by  its  "  cata- 
lytic" effects, — that  is  to  say,  by  its  influence  on  the  vessels,  upon  exudation  and  the  pro- 
cesses of  nutrition, — it  exerts  a  wide  effect  on  those  neuralgias  which  are  influenced  by 
the  faradic  current.  There  are  two  methods  of  applying  faradic  electricity  (interrupted 
current) :  a.  By  conducting  a  strong  current  of  the  secondary  spiral  for  a  few  minutes 
through  the  nerve  by  means  of  moist  electrodes,  one  of  them  being  placed  on  the  nerve- 
trunk  as  near  as  possible  to  its  central  origin ;  this  plan  must,  for  the  most  part,  be  fre- 
quently repeated,  b.  By  producing  energetic  irritation  of  the  skin  with  an  electric  brush, 
in  the  region  of  the  distribution  of  the  nerve  at  its  point  of  emergence  and  over  the 
points  douloureux.  The  application  of  galvanic  electricity  is  especially  intended  to 
modify  the  nutritive  processes  taking  place  in  the  nerve,  to  produce  the  so-called  cata- 
lytic effects,  and  to  lower  the  irritability  of  the  nerves.  The  result  of  its  application, 
either  according  to  the  polar  or  the  direction  method,  seems  to  be  equally  good.  In  the 
polar  method,  the  anode  (positive  electrode)  is  applied  first  upon  the  nerve  trunk  (when 


5IO  PSYCHOLOGICAL    MEDICINE. 

possible,  in  the  immediate  vicinity  of  the  proper  focus  of  the  disease)  and  then  upon  the 
point  douloureux,  and  the  cathode  (negative  electrode)  upon  some  indifferent  point. 

In  the  direction  method,  the  descending  direction  is  used  by  preference,.and  the  anode 
(positive  electrode)  is  then  to  be  placed  upon  the  plexus  or  upon  the  roots  of  the  nerve, 
and  the  cathode  (negative  electrode)  is  to  be  placed  upon  the  nerve-trunk  and  the  pain- 
ful points.  As  a  rule,  the  duration  of  the  sitting  should  be  short,  extending  over  from 
two  to  eight  minutes,  and  repeated  daily,  or  every  other  day. 

The  strength  of  the  current  must  in  general  be  moderate.  The  effects  are  usually  ex- 
perienced at  once,  and  continue  for  a  variable  period,  from  two  or  three  to  twenty-four 
hours,  ultimately,  after  a  variable  number  of  sittings,  becoming  permanent. 

On  cases  treated  successfully  by  the  spine-bag,  Dr.  John  Chap- 
man, Physician  to  the  Farringdon  Dispensary,  London,  says : 

The  cure  of  neuralgia,  whether  the  disease  be  treated  by  drugs  given  internally,  or  by 
applications  of  various  kinds  at  the  seat  of  pain,  or  by  the  two  methods  conjointly,  is 
confessedly  almost  always  difficult,  and  in  a  large  proportion  of  cases  impossible.  The 
cases  reported  below  have  been  treated  by  a  method  altogether  new.  By  stating  each 
case  with  extreme  brevity,  I  am  enabled  to  present  at  one  view  within  a  small  compass  the 
results  of  several  experiments;  and  I  do  this  in  the  hope  that  they  may  produce  such  an 
impression  on  the  minds  of  professional  readers  as  may  impel  them  to  acquaint  them- 
selves with  the  pathological  and  therapeutical  principles  of  which  these  results  are  an 
expression.  I  shall  hereafter  publish  an  exposition  of  those  principles,  illustrated  by 
reports  of  cases  hi  extenso,  and  shall  then  give  a  full  description  of  the  treatment  adopted. 

1.  Facial  Neuralgia. — T.  H.,  a  gentleman,  aged  35,  who  had  been  suffering  during 
the  previous  fortnight,  requested  my  advice  March  18,  1865.  He  was  in  great  pain, 
which  had  been  continuous  from  the  previous  day,  and  which  had  wholly  deprived  him 
of  sleep.  The  pain  was  chiefly  on  the  right  side  of  the  face  and  head;  but  during  the 
morning  preceding  my  visit  the  left  side  had  become  invaded.  The  affected  parts  were 
verj'  tender,  and  somewhat  swollen.  The  head  was  rather  hot,  the  face  flushed,  the 
tonoTie  thinly  coated  with  whitish  fur ;  pulse  92,  full  and  strong.  Several  medicines  pre- 
scribed by  two  phy^-icians  in  succession  had  proved  of  no  avail. 

I  applied  a  ten-inch  spinal  water-bag,  containing  water  at  130°  F.  to  the  cervico  dorsal 
region,  and  shortly  afterwards  left  the  patient's  room.  Within  half  an  hour  I  returned, 
•when  I  found  him  asleep.  The  treatment  was  continued  for  two  days  by  means  of  heat ; 
afterwards  I  used  ice  (at  first  in  the  lumbar  region),  and  from  the  time  he  first  fell  asleep 
he  continued  free  of  pain,  which  has  not  since  returned. 

2.  Facial  Neuralgia. — Fraulein  S.,  aged  about  25,  consulted  me  February  3,  1867, 
on  account  of  neuralgia  affecting  the  infra-orbital  and  dental  branches  of  the  trifacial 
nerve.  The  pain  was  not  confined  to  one  side  of  the  face,  but  was  sometimes  most  acute 
on  one  side,  sometimes  on  the  other;  it  increased  at  night,  and  kept  her  awake  the  greater 
part  of  each  night.  She  had  been  suffering  in  this  way  for  about  three  weeks  before  I 
saw  her.  Her  general  health  was  good.  The  affected  part  presented  no  trace  of 
hyperaemia. 

She  was  treated  by  means  of  ice,  and  experienced  almost  immediate  relief.  After 
three  days  of  treatment  she  felt  and  slept  very  much  better;  and  before  the  end  of  the 
fifth  day  the  pain  had  wholly  ceased.  Nearly  a  year  afterwards  she  told  me  that  it  had 
never  returned. 

3.  /a«,7/A>wrff/^za.— Mademoiselle  M.,  aged  20,  consulted  me  in  August,  1867,  when 
she  was  suffering  from  acute  facial  neuralgia,  the  chief  foci  of  which  were  the  infra- 


NEURALGIA.  5  1 1 

orbital  foramen  and  the  mental  foramen  of  the  right  side.  The  extreme  pain  came  on 
in  fits,  sometimes  at  8  a.m.,  sometimes  at  2  p.m.  ;  but  between  the  paroxysms  the  face 
continued  to  ache,  and  at  times  the  patient  had  pain  at  the  back  of  the  head.  She  had 
suffered  in  this  way  about  a  fortnight  before  coming  to  me,  and  had  had  several  similar 
attacks  during  the  preceding  year. 

The  treatment  consisted  in  the  application  of  the  double-columned  hot  water-bag. 
The  malady  was  immediately  subdued ;  no  distinct  paroxysm  occurred  after  the  first 
application  of  heat ;  all  pain  rapidly  and  completely  subsided,  and  since  that  date  has 
not  returned. 

4.  Dettial  Neuralgia. — A.  W.  B.,  a  Russian  gentleman,  suffering  from  dental  neu. 
ralgia,  consulted  me  in  September,  1867.  The  malady  was  chiefly  confined  to  the  teeth 
of  both  upper  and  lower  jaw,  but  no  particular  tooth  or  teeth  seemed  to  be  especially 
affected.  The  pain  was  intermittent,  and  so  severe  as  to  interfere  seriously  with  the 
patient's  daily  occupation.  No  cause  of  the  disorder,  which  had  continued  some  weeks, 
could  be  discovered ;  and  the  face,  so  far  from  showing  any  sign  of  hyperemia  over  the 
seat  of  pain,  seemed  cooler  than  normal.  In  the  course  of  the  first  day  of  treatment  by 
means  of  the  spinal  ice-bag,  the  pain  was  completely  subdued ;  the  cold  was  persisted  in 
for  some  time,  and  during  the  remainder  of  the  patient's  stay  in  England  he  continued 
free  from  suffering. 

5.  Dental  Neuralgia. — H.  E.,  female,  aged  21,  suffering  from  violent  and  continuous 
pain,  spreading  over  the  teeth  and  gums  of  both  the  upper  and  lower  jaw,  consulted  me 
January  17,  1868.  The  pain  was  most  intense  in  the  lower  jaw  and  on  the  left  side;  she 
had  intense  headache  also.  The  forehead  and  cheeks  were  notably  hotter  than  normal, 
and  she  complained  of  great  heat  in  the  roof  of  the  mouth  as  well  as  in  the  gums,  which 
were  swollen  and  sore.  During  the  previous  week  she  had  had  several  teeth  stopped 
with  gold ;  one  of  them  became  most  especially  painful ;  and  there  was  threatening  of 
an  abscess  at  its  root. 

The  treatment  consisted  in  the  application  of  cold  across  the  occiput,  and  of  heat  over 
the  cilio- spinal  region, — in  the  first  instance  separately,  and  afterwards  simultaneously. 
The  pain  was  speedily  and  completely  annulled ;  it  recurred,  and  was  again  annulled  by 
the  same  method  on  several  occasions.  The  patient  volunteered  the  statement  that, 
during  the  application  of  the  heat,  her  mouth  became  perceptibly  cooler. 

6.  Facial  and  Brachial  Neuralgia. — Mary  A.  T.,  aged  44,  first  consulted  me  at  the 
Farringdon  Dispensary,  December  28,  1867,  when  .she  was  suffering  from  neuralgia  of 
the  right  side  of  the  head,  face,  and  neck,  and  along  the  right  shoulder  and  arm,  extend- 
ing to  the  fingers.  The  right  half  of  the  tongue  was  also  affected.  The  pain,  which 
was  exactly  limited  to  the  median  line,  was  described  by  the  patient,  "  like  as  if  some- 
thing is  pulling  the  flesh  off  the  bone,  it's  so  dreadful,  and  sometimes  as  if  the  parts  were 
screwed  up  in  a  vice." 

She  was  treated  by  means  of  ice  applied  along  the  whole  spine.  She  improved  imme- 
diately and  rapidly,  and,  as  early  as  January  15th,  informed  me  that  she  had  not  had  "  a 
bit  of  neuralgia"  during  the  whole  of  the  preceding  week.  Up  to  this  date  (February 
22d),  the  pains  have  not  returned. 

7.  Intercostal  attd  Hypogastric  Neuralgia. — Miss  E.,  who  first  consulted  me  January 
14,  1865,  complained  of  extreme  pain  on  the  right  side  of  the  lower  dorsal  and  upper 
lumbar  vertebrae,  extending  outwards  and  thence  forwards  to  the  right  hypogastric  region. 
The  pain  had  continued  every  day  and  night,  with  occasional  intervals  of  three  or  four 
hours'  release  from  suffering,  and  had  lasted  about  twenty  years.  The  pain  was  so  dis- 
tressing and  wearing  that  the  patient's  strength  had  become  much  impaired,  especially  by 
loss  of  sleep,  and  she  was  unable  to  undertake  any  regular  occupation.     The  only  sleep 


512  PSYCHOLOGICAL   MEDICINE. 

she  could  get  was  induced  by  brandy  and  narcotics.  She  suffered  also  nearly  every 
morning,  and  frequently  throughout  the  day  from  nausea,  and  occasionally  vomited 
"  water." 

I  directed  the  patient  to  leave  oif  brandy,  opium,  and  morphia  at  once  and  entirely, 
and  treated  her  chiefly  by  means  of  ice  along  the  lower  half  of  the  spine.  As  early  as 
February  14th,  the  patient  was  enabled  to  say  to  me, — "  During  the  last  few  nights  I 
have  slept  throughout  the  night  without  being  disturbed  at  all,  an  experience  quite  new 
to  me."  On  the  first  of  the  following  April  she  informed  me  that  she  had  already  been 
many  days  absolutely  free  from  pain.  The  nausea  and  vomiting  had  ceased,  and  the 
bowels  had  become  "  open  every  day — quite  a  new  feature."  I  have  since  heard  from 
time  to  time  that  this  patient  continues  well. 

8.  Intercostal  Neuralgia. — A  man  came  to  the  Farringdon  Dispensary,  October  21, 
1867,  and  complained  to  Dr.  Drysdale,  whose  patients  I  was  seeing  with  him,  of  acute 
pain  along  one  side  of  the  chest ;  no  assignable  cause  for  it  could  be  detected,  and  we 
regarded  it  as  a  case  of  intercostal  neuralgia.  I  recommended  the  application  of  the 
spinal  ice-bag  along  the  dorsal  spine  twice  a  day.  "  Sometime  afterwards,"  as  Dr.  Drys- 
dale related  to  the  Harveian  Society,  "  the  man  returned  to  the  dispensary  looking  so 
delighted  that  the  doctor  asked  him  what  was  giving  him  so  much  pleasure  ?  when  he 
replied  that  the  '  ice-bag  had  done  him  a  world  of  good ;  it  had  taken  away  all  his  pain 
with  wonderful  quickness.'  " 

9.  Intercostal  Neuralgia. — Mary  B.,  aged  51,  first  seen  by  me  November  27,  1867, 
complained  of  intense  pain  over  the  right  shoulder,  between  the  scapulae  and  along  the 
right  side  of  the  chest.  During  the  attacks  of  pain,  which  came  on  and  went  away  sud- 
denly, the  flesh,  she  said,  quivered  and  tingled.  She  felt  her  body  bent  down  as  if  she 
could  not  move  it  for  fear  of  the  pain. 

She  was  treated  by  the  application  of  the  spinal  ice-bag  along  the  lower  half  of  the  spine 
during  an  hour  twice  a  day.  The  patient  was  surprised  to  find  herself  already  quite  free 
from  pain  during  November  29th  and  30th.  Early  in  December  it  recurred  very  slightly, 
but  on  the  18th  she  said  she  remained  free  from  neuralgia,  except  slight  pain  in  the  even- 
ing when  fatigued  by  her  work;  she  became  much  stronger,  and  was  not  so  "nervous;" 
by  December  28th  all  pain  had  gone ;  and  February  26th,  when  I  last  saw  her,  it  had 
not  returned. 

10.  Chest-Ache. — October  21,  1867,  I  was  asked  at  the  P'arringdon  Dispensary  by  Dr. 
Drysdale  to  prescribe  for  one  of  his  patients,  Maria  Williams,  aged  22,  who  was  then 
suffering  from  continuous  aching  beneath  the  right  clavicle,  together  with  "  dreadful 
pains"  in  the  head,  dizziness,  heaviness  in  the  morning,  and  profuse  leucorrhoea,  which 
had  lasted  several  months. 

I  prescribed  the  application  of  a  narrow  16-inch  ice-bag  along  the  spine  during  30'' 
twice  a  day, — the  bottom  of  the  bag  being  placed  on  a  level  with  the  fourth  lumbar 
veitebra. 

October  26th.  The  patient  reported  that  the  ice-bag  had  done  her  "  a  wonderful  deal 
of  good;"  that  the  leucorrhoea  had  stopped,  and  that  «// her  head  symptoms  had  van- 
ished. I  requested  her  to  persist  in  the  treatment  previously  prescribed.  By  November 
2d  the  pain  beneath  the  right  clavicle  had  quite  ceased,  and  no  one  of  all  her  troubles 
previously  got  rid  of  had  recurred. 

11.  Mammary,  Ovarian,  and  Uterine  Neuralgia. — H.  M.,  a  girl  aged  17,  who  was 
first  seen  by  me  February  24,  1863,  and  who  was  suffering  from  daily  attacks  of  epilepsy 
{petit  mal),  complained  of  extreme  pain  in  the  region  of  the  left  ovary,  which  was  tender 
on  pressure,  and  increasingly  so  immediately  before  the  patient's  menstrual  periods ;  also 


NEURALGIA.  513 

of  pain  in  the  right  mamma,  which  was  considerably  larger  than  the  left,  and  of  "  fearful 
cutting  pains"  in  the  womb  during  menstruation. 

I  treated  this  case  chiefly  by  means  of  iced-water  applied  along  the  spine.  The  result 
was  complete  cessation  of  the  mammary,  ovarian,  and  uterine  pains ;  the  mammae  be- 
came of  equal  size ;  and  the  epileptic  vertigo,  which  had  continued  many  years,  ceased 
entirely  a  month  after  the  treatment  began,  and  has  never  recurred. 

12.  Neuralgia  of  the  Legs. — I  was  consulted  June  25,  1867,  by  Mr.  ,  M.P.,  aged 

49,  who  complained  of  excruciating  neuralgia  in  the  legs.  The  pain  was  of  the  ordinary 
tearing,  shooting,  and  stabbing  kind,  sometimes  in  one  limb,  sometimes  in  the  other,  and 
affecting  one  heel  almost  continuously.  This  was  often  so  acutely  tender  that  he  could 
not  bear  to  touch  the  ground  with  it.  As  a  rule  the  patient  suffered  most  at  night,  and 
could  rarely  get  any  refreshing  sleep.  The  malady  came  on  about  sixteen  years  ago,  and 
had  recurred  at  intervals  ever  afterwards.  Until  the  morning  he  came  to  me  he  had 
never  been  free  of  intense  pain  for  nineteen  days.  The  patient  was  in  the  habit  of  drink- 
ing daily  about  a  pint  of  sherry,  which  I  advised  him  to  give  up. 

The  treatment  consisted  in  the  application  of  a  spinal  ice-bag  along  the  lumbar  and 
the  lower  half  of  the  dorsal  vertebrae.  The  patient  informed  me,  July  25th,  that,  "prac- 
tically speaking,"  he  had  had  no  pain  since  he  began  the  treatment,  and  that  he  had  slept 
well.  I  advised  perseverance  with  the  ice,  and  abstinence  from  wine.  The  patient  wrote 
to  me,  August  21st,  "  I  continue  to  receive  great  benefit  from  the  ice  application,  and 
shall  continue  it."  The  pain  afterwards  recurred  in  a  mitigated  form,  but  was  greatly 
subdued  by  the  ice,  and,  I  incline  to  believe,  would  be  quite  cured  if  the  patient  would 
wholly  abstain  from  wine. 

13.  General  Neuralgia. — June  22,  1855,  I  was  consulted  by  Lord  — — ,  on  account  of 
neuralgia  affecting  different  parts  of  the  body ;  the  walls  of  the  chest  and  the  lower  ex- 
tremities were  chiefly  involved.  The  attacks  generally  came  on  suddenly,  and  lasted 
about  fifteen  hours,  sometimes  longer.  The  pains  were  of  an  acute,  stabbing,  and  seem- 
ingly spasmodic  character,  and  were  often  brought  on  by  vigorous  muscular  exercise, 
especially  deer-stalking,  which  his  lordship  is  very  fond  of,  but  which  his  attacks  either 
cut  short  or  prevented  him  from  indulging  in. 

I  prescribed  the  application  of  ice  along  the  spine,  and  five  graiins  of  citrate  of  iron 
and  quinine  during  a  few  days  at  a  time  occasionally.  When  I  saw  the  patient  again, 
April  27,  1866,  he  informed  me  that  he  had  applied  the  spinal  ice-bag  as  directed  during 
several  weeks  at  a  time  at  three  successive  periods  since  he  consulted  me.  He  declared 
himself  so  greatly  improved  that  he  had  been  quite  free  from  his  malady  for  long  periods 
together ;  that,  when  it  had  recurred,  the  pains  had  been  comparatively  slight ;  that  he 
could  resume  violent  exercises,  including  deer-stalking,  without  bringing  on  an  attack ; 
and  that  in  his  opinion,  had  he  continued  the  treatment  regularly  for  a  longer  time,  he 
should  have  been  completely  cured. 

14.  General  Neuralgia. — Hannah  E.  complained  to  me,  January  4,  1868,  at  the  Far- 
ringdon  Dispensary,  of  great  pain  in  all  the  four  limbs,  but  most  especially  in  the  fingers 
and  toes,  and  in  the  left  side  over  a  spot  about  the  size  of  half-a-cijown  ;  of  headache 
each  morning;  of  "dreadful"  backache;  and  of  excessive  irritability  of  the  bladder, 
involving  the  necessity  of  urinating  about  every  five  minutes. 

She  was  treated  by  the  application  of  the  lumbar  ice-bag,  90^,  twice  a  day.  Within  a 
week  the  pain  in  the  limbs  was  almost  wholly  gone.  By  the  15th  of  January  it,  as  well 
as  her  headaches,  had  quite  ceased;  her  back  was  much  better;  and  she  was  obliged  to 
micturate  only  about  every  hour.  On  the  5th  of  February  she  reported  herself  free  from 
every  pain  on  account  of  which  she  had  consulted  me,  and  the  irritability  of  the  bladder 
was  so  much  lessened,  that  she  was  only  troubled  with  it  at  intervals  of  about  90'. 

i2> 


5  14  PSYCHOLOGICAL    .MEDICINE. 

On  certain  forms  of  visceral  neuralgia,  Dr.  Clifford  Allbutt,  Leeds, 
says  : 

[Neuralgia  of  internal  organs  has  only  lately  received  the  attention  which  it  deserves.] 
Gasiralgia  is,  perhaps,  the  commonest  form  of  pain,  from  which  some  neurotic  patients 
suffer,  and  it  really  is  so  easy  to  distinguish  from  dyspepsia,  that  one  regrets  the  more 
they. so  commonly  are  confounded.  Its  occurrence  in  the  persons  I  have  described  makes 
it  scarcely  necessary  to  add  that  it  is  far  commoner  in  women  than  in  men.  I  do  not  re- 
member ever  seeing  it  as  a  lai-val  fot  m  ni  malarious  disease.  Our  present  physiological 
knowledge  discredits  its  supposed  connection  with  the  cceliac  plexus,  and  refers  the  seat  of 
pain  rather  to  the  vagus  ;  this,  indeed,  our  clinical  knowledge  supports,  for  Anstie  has 
shown  that  gastralgia  often  runs  with  angina  and  with  asthma.  It  occurs  mostly  after  the 
following  fashions  :  Sudden  and  violent  pain  may  seize  the  gastric  region,  sometimes  biting 
right  into  the  epigastrium,  sometimes  darting  through  to  the  back,  sometimes  gnawing  at 
almost  all  the  sternal  region,  sometimes  twisting  and  griping  from  the  epigastrium  round 
the  false  ribs  to  the  left.  The  attacks  may  come  on  so  suddenly  as  (in  one  case  now  un- 
der my  care)  to  interrupt  the  sufferer  in  conversation,  and  drive  him  into  another  room  to 
writhe  in  secret,  or  they  may  come  on  more  gradually,  and  never  reach  any  great  degree 
of  intensity.  In  either  case  they  have  periods  of  greater  and  less  severity,  and  of  actual 
remission,  long  or  short.  Pressure,  as  in  colic,  generally  relieves  rather  than  ag- 
gravates, and  the  attack  passes  off  to  recur  at  intervals  which  seldom  seem  to  observe 
any  remarkable  constancy.  With  the  sensory  disturbances  are  often  associated  motor 
disorders.  In  one  marked  case — that,  to  which  I  have  already  alluded — the  stomach  is 
the  seat  of  volcanic  movements  of  a  flatulent  character,  as  flatulence  is  associated  also  with 
abdominal  colic.  Twistings  and  irresistible  gatherings  of  wind,  which  belch  loudly  from 
the  throat,  may  accompany,  follow,  or  replace  the  gastralgia,  are  dreaded  by  the  patient 
as  much  as  the  pain,  and  are  amenable  to  like  palliatives, — to  subcutaneous  morphia,  for 
instance, — while  they  set  all  alkalies,  carminatives,  antiseptics,  and  stomachics  at  utter 
defiance.  In  other  instances  some  catarrh  of  the  stomach  is  associated  with  gastralgia, 
a5  diarrhcea  may  accompany  "  interalgia,"  but  this  is  less  common.  More  common  is 
vomiting,  which  may  be  spasmodic,  or  may  be  a  revolt  of  the  hypersesthetic  stomach 
against  the  touch  of  the  food.  In  the  case  of  Sarah  S.,  which  I  shall  presently  describe, 
the  vomiting  was  a  very  prominent  symptom.  In  some  cases  functional  disturbances, 
elsewhere  seem  not  .only  to  be  an  outcome  of  the  same  general  habit,  but  to  be  directly 
consequent  upon  the  gastralgia  itself,  though,  of  course,  this  is  hard  to  prove.  Irritable 
heart  and  wiry  pulse,  however,  are  very  often  associated  with  gastralgia  in  a  way  which 
seems  rather  direct  than  indirect.  Asthma  and  angina  seem  rarely  to  have  the  direct 
but  often  the  indirect  connection,  as  they  occur,  not  at  the  same  time,  but  at  different 
times  in  the  same  person.  Spasm  of  the  abdominal  walls  is  often  present ;  perhaps  we 
should  always  find  it  if  we  stripped  the  patient.  The  recti  abdominis  are  knotted  and 
the  belly  and  epigastrium  are  nipped  into  hollows.  This  is  mainly  a  reflex  act,  and  the 
parts  are  at  once  released  (as  I  have  had  occasion  twice  to  notice)  by  a  few  whiffs  of 
chloroform.  "Points  douloureux  "  seem  scarcely  to  exist;  certainly  the  epigastrium  is 
rarely  so  tender  as  in  dyspepsia  and  gastritis.  Most  persons,  unless  of  a  verj'  vigorous 
and  hard  condition,  have  occasional  tender  vertebrre;  and  few  women  will  not  complain 
of  differences  in  places  when  the  spinous  processes  are  successively  pressed.  The  parox- 
ysms may  give  way  as  suddenly  as  they  came,  or  they  may  vanish  slowly  ;  the  intervals 
are  generally  complete,  or  nearly  so,  but  the  motor  disturbances  may  intervene  and  the 
interval  be  diversified  by  uncontrollable  belching  or  capricious  vomiting.  Nausea,  I 
think,  is  rare.     Now,  from  what  has  gone  before,  it  will  be  seen  that  the  confusion  be- 


NEURALGIA.  5  I  5 

tween  gastralgia  and  dyspepsia  is  not  to  be  excused.  There  is  no  sharp  pain  from  the 
epigastrium  to  the  shoulders,  consequent  only  upon  injection  of  food,  and  relieved  by 
vomiting  or  the  prone  position.  The  pain  takes  its  own  times  of  ebb  and  flow  quite  in- 
dependently of  digestion,  for  in  some  cases  indeed  food  gives  relief;  not  long  ago  I 
almost  cured  a  gastralgia  by  advising  a  patient,  who  had  been  starved  for  dyspepsia,  to 
go  home  and  live  as  generously  as  he  could  for  a  fortnight.  He  was  utterly  amazed  to 
find  that,  so  far  from  being  the  vi'orse  for  it,  he  was  actually  better  and  better.  Nor  are 
there  any  truly  dyspeptic  -symptoms;  the  tongue  is  rarely  coated;  red  at  tip  and  edges 
it  may  be,  but  often  it  is  of  thoroughly  normal  aspect;  nor  do  the  other  symptoms,  as 
observed  in  the  secretions,  in  abnormal  vomits,  risings,  acidity,  and  the  like,  bear  out 
the  supposition  of  present  dyspepsia.  At  the  same  time,  the  mucous  membrane  of  these 
neurotics  is  often  irritable,  and  may  also  be  subject  to  intercurrent  catarrh.  In  the  va- 
porous neuralgics  the  tongue  is  frequently  large,  flabby,  and  white  at  the  back,  the 
breath  rather  faint  in  odor,  and  constipation  invariable ;  while,  in  the  irritable  neu- 
rotics, the  tongue  is  nearly  always  small  and  often  red  at  the  tip  and  edges,  the  breath, 
however,  being  sweet,  and  the  motions,  though  often  constipated,  yet  often  again  run- 
ning into  diarrhoea.  Bismuth,  with  small  opiate  additions,  or  oxide  of  silver  are  not 
uncommonly  necessary  in  the  kind  of  dyspepsia  which  may  undoubtedly  complicate 
gastralgia. 

It  is  with  unusual  pleasure  we  enter  upon  the  treatment  of  gastralgia,  for,  instead  of 
admitting  our  weakness,  here  we  are  certainly  strong.  Individual  cases  may,  indeed, 
thwart  us;  but,  as  a  rule,  we  can  hardly  fail  to  bring  considerable  relief.  The  continu- 
ous current  I  have  rarely  tried  in  visceral  neuralgias,  and,  gastralgia  being  so  often  a 
complaint  of  women,  it  is  seldom  convenient  to  make  any  local  application  of  this  rem- 
edy. The  first  step  to  be  taken,  after  forming  a  diagnosis,  is  to  assure  the  patient  that 
his  complaint  is  not  dyspepsia  but  neuralgia,  and  to  put  him  upon  diet  as  liberal  as  the 
worried  stomach  will  tolerate.  This  must  be  done  carefully.  There  are  to  be  no  large 
full  meals,  but  small  quantities  of  light  nutritious  food  at  frequent  intervals  during  the 
day.  Rum  and  milk  in  the  morning,  a  little  meat  for  breakfast,  without  much  slop,  a 
raw  egg  or  a  basin  of  soup  at  noon,  a  chop  at  the  luncheon  hour,  with  a  glass  of  sherry 
and  vegetables  in  moderation,  tea  and  bread  and  butter  at  five,  meat  and  light  pudding 
at  half-past  six,  with  another  glass  of  wine,  and  before  bed  a  small  cup  of  revalenta,  with 
a  biscuit.  Cod-iiver  oil  will  in  most  or  many  cases  be  required.  And  the  patient,  being 
released  as  to  diet,  must  now  be  strictly  warned  as  to  the  real  causes  of  his  ailment ; 
anxiety  in  home  or  business,  many  important  engagements,  prolonged  suckling,  teaching 
in  schools  during  hours  due  to  relaxation,  reading  at  night,  social  dissipations;  all  these 
causes  of  "wear"  must  be  inquired  into  and  disposed  of.  The  next  important  indica- 
tion is  to  administer  such  medicines  as  the  case  seems  to  call  for  on  more  general  grounds. 
Anaemia,, which  cannot  alone  cause  gastralgia,  but  often  favors  its  manifestation,  must  be 
met  by  steel  and  aloes.  I  think  Dr.  Anstie  has  said  that  the  tincture  of  the  sesquichlo- 
ride  of  iron  seems  to  have  a  .special  power  over  neuralgia, — a  power  which  can  scarcely 
be  due  to  a  mere  improvement  in  the  blood.  This  may  be  so ;  certainly  in  one  case  of  ob- 
stinate frontal  neuralgia,  with  a  white  lock  of  hair,  which  was  long  under  my  hands,  and 
in  which  everything,  galvanism  included,  had  failed ;  in  this  case,  large  doses  of  the 
tincture  of  the  sesquichloride  succeeded  better  than  any  other  remedy.  But  the  same 
thing  used  to  be  said  concerning  the  carbonate  of  iron,  and  probably  with  equal  truth ; 
so  that  the  special  virtue,  if  any,  resides  in  the  metal,  and  not  in  one  of  its  salts  alone. 
It  would  appear,  then,  that  in  iron  we  have  two  kinds  of  value ;  its  value  in  ordinary 
small  doses  and  in  mild  forms,  when  it  removes  simple  anaemia,  and  its  value  in  large 
doses, — doses  such  as  half  a  drachm  to  a  drachm  of  carbonate  of  iron,  or  of  twenty  tO' 


5l6  PSYCHOLOGICAL    MEDICINE. 

thirty  drops  of  the  sesqui chloride  tincture, — when  it  seems,  apa.rt  from  the  presence  of 
any  definite  anaemia,  to  have  a  special  effect  in  modifying  the  morbid  state  of  nerve-tissue- 
The  same  is  true  in  some  sense  of  quinine.  This  drug  may  be  used  in  common  doses 
of  about  a  grain  as  a  simple  tonic,  or  in  doses  of  ten  to  thirty  grains  as  an  anodyne. 
But  I  have  here  to  refer  to  its  use  in  the  former  way  only,  for  large  doses  of  quinine 
seem  to  have  little  palliative  value  in  gastralgia,  a  fact  which  surprised  me,  seeing  that 
the  trigeminal  centre  and  the  vaso-motor  centre,  over  which  they  have  such  power,  are 
close  to  the  nucleus  of  the  vagus.  Probably,  however,  quinine  governs  trigeminal  neu- 
ralgia indirectly  through  the  intermediation  of  vaso-motor  change.  Be  this  as  it  may, 
small  doses  of  quinine  with  strychnine  make  a  capital  chronic  medicine  for  gastralgia; 
but  large  doses,  as  rapid  agents,  in  this  ailment  seem  impotent.  In  the  above  combina- 
tion the  strychnine  is,  however,  the  more  valuable  element,  and  few  cases  of  gastralgia 
get  on  altogether  without  it.  It  probably  acts  best  when  given  under  the  skin;  but,  until 
baffled  in  other  attempts,  one  scarcely  resorts  to  this  form  of  administration.  In  the  few 
instances  where  I  have  thus  tried  it,  I  have  seen  excellent  results.  Small  doses  should 
be  repeated  daily  for  several  days,  and  the  medicine  carefully  strengthened,  if  necessary, 
as  its  effects  are  seen.  But  of  all  the  remedies  for  gastralgia  arsenic  is  king,  and  to  the 
use  of  arsenic  I  was  led,  when  ignorant  of  its  use  by  others,  by  noting  the  frequent  con- 
currence of  certain  skin  affections  with  gastralgia.  Eczema,  psoriasis,  lichen,  herpes, 
urticaria,  all  run  with  gastralgia  in  the  irritable  neurotics,  and  the  eruptions  generally 
occur  in  active,  spreading,  itching,  hypersemic,  symmetrical  forms.  In  gouty  persons,  on 
the  contrary,  they  are  generally  circumscribed  and  chronic.  Arsenic,  then,  has  some 
remarkable  power,  not  over  skin  affections  in  general,  but  as  they  occur  in  these  neu- 
rotics ;  and  it  likewise  cures  or  relieves  their  migraine,  their  tics,  their  asthma,  their  an- 
gina, their  gastralgia,  their  colic,  their  capricious  diarrhoea.  Arsenic  has  not  any  specific 
power  over  skin  affections  merely  as  such,  and  hence  the  frequent  disappointment  of  those 
who  so  use  it ;  but  it  is  a  remarkable  modifier  of  a  certain  peculiar  constitutional  habit,  of 
which,  probably  by  way  of  the  nervous  system,  it  obviates  the  morbid  tendencies.  I 
always  prescribe  Fowler's  solution  in  any  simple  water,  a  dose  of  which,  containing  three 
to  five  drops  of  the  solution,  is  taken  largely  diluted  thrice  daily  with  meals.  It  should 
be  carefully  pushed  to  the  edge  of  its  physiological  effects.  The  only  palliative  remedy 
of  any  importance  is  morphia  used  hypodermically,  and  of  this  I  shall  treat  when  I  come 
to  speak  also  of  ovaralgia ;  of  the  lesser  palliatives  the  best,  I  think,  are  ether  and  chloro- 
form given  internallj'  in  small  doses. 

Respecting  the  treatment  of  "  epileptiform  neuralgia,"  Francis  E. 
Anstie,  M.  D.,  F.  R.  C.  P.,  Senior  Physician  to  the  Westminster  Hos- 
pital, has  made  some  important  remarks  upon  the  treatment  in  the 
earlier  stages  of  that  terrible  kind  of  facial  neuralgia  to  which  Trous- 
seau gave  the  name  of  "  epileptiform." 

Trousseau  has  described,  with  the  brilliant  eloquence  so  peculiarly  his  own,  the  tragic 
prospect  which  the  sufferer  from  spasmodic  tic  has  before  him ;  how  hopeless  it  is  that 
he  should  obtain  a  cure,  and  how  certain  that  any  relief  obtained  by  remedies  will  be 
followed  by  a  return  of  all  his  sufferings.  He  has  laid  it  down  as  an  absolute  law  that 
we  are  to  expect  nothing  but  a  temporary  respite  or  alleviation ;  and  he  then  proceeds  to 
say  that  this  minor  amount  of  good  is  to  be  procured  by  very  large  and  increasing  doses 
of  opium  better  than  by  any  other  means. 

There  is  no  doubt  that  Trousseau's  description  of  spasmodic  facial  neuralgia,  as  a  dis- 


NEURALGIA.  5  I  / 

ease  hopeless  of  cure,  was,  at  the  moment,  nearly  correct.  He  is  evidently  speaking  of  a 
malady  quite  different  from  the  milder  neuralgia  which  may  occur  at  any  time  of  life, — 
a  neuralgia  which  is  rare,  is  confined  to  certain  highly  neurotic  families,  and  which, 
among  those  families,  only  attacks  a  limited  number  of  individuals  who  have  passed  the 
prime  of  life  and  entered  upon  the  period  of  organic  degeneration.  The  pain  is  of 
frightful  severity,  and  is  all  the  more  difficult  to  bear  because  of  the  agonizing  sudden- 
ness with  which  it  darts  through  the  affected  nerve,  perhaps  aroused  by  some  trifling  and 
necessary  muscular  movement,  such  as  mastication.  That  very  large  doses  of  opium  are 
required  to  produce  any  great  impression  on  the  disease,  if  the  medicine  be  given  by  the 
stomach,  is  also  perfectly  true.  These  doses  must  be  continued,  and  rapidly  increased, 
with  the  unfailing  effect  of  seriously  disordering  the  functions  of  digestion  and  assimila- 
tion. And,  after  all,  the  best  result  attainable  is,  that  for  a  few  weeks  or  months  there 
may  be  a  notable  diminution  of  the  severity  of  the  pain,  but  with  the  certainty  that, 
sooner  or  later,  it  will  revive  in  all  its  intensity,  and  that  then  opium  nor  anything  else 
will  produce  any  perceptible  impression  upon  it.  The  remainder  of  such  a  patient's  life 
is  rendered  additionally  miserable,  in  most  cases,  by  a  total  derangement  of  digestion  and 
consequent  failure  of  nutrition. 

Dr.  Anstie  believes  that  a  very  miich  better  result  than  this  may  be  obtained  if  the  mal- 
ady be  treated,  from  an  earlier  stage,  according  to  the  following  plan  :  i.  Counter-irrita- 
tion of  a  peculiar  kind.  2.  Nutritive  tonics.  3.  Subcutaneous  injection  of  morphia,  or 
of  atropia,  according  to  circumstances. 

I.  Counter-irritation,  to  be  useful  in  epileptiform  facial  tic,  should  not  be  applied  to 
the  branches  of  the  fifth,  but  to  those  of  the  occipital  nerve,  at  the  nape  of  the  neck.  A 
blister  in  the  former  situation  is  as  often  hurtful  as  useful ;  in  the  latter  it  is  sometimes 
strikingly  effective  in  gaining  a  short  respite.  And  this  is  of  very  great  importance  in  this 
awful  disease,  for  the  mere  fact  of  such  pain  being  allowed  to  continue  is  itself  the  worst 
possible  omen.  2.  The  assiduous  use  of  cod-liver  oil,  or  of  some  fatty  substitute  for  it, 
should  be  insisted  on  from  the  first,  and  is  of  the  highest  consequence.  3.  Subcutaneous 
injection  places  us  in  a  totally  different  position  toward  the  use  of  opium  in  spasmodic 
tic.  There  is  no  longer  any  excuse  for  the  use  of  enormous  doses  of  opium  from  the 
first.  It  will  be  sufficient  to  commence  with  the  use  of  one-sixth  of  a  grain  of  morphia 
twice  daily,  increasing  this,  if  necessary,  to  one-fourth  and  one-half  a  grain,  and,  in  rare 
cases,  to  one  grain.  If  this  produces,  along  with  the  other  measures,  a  notable  remis- 
sion of  the  pain,  it  should  be  cautiously  and  steadily  decreased,  as  circumstances  may 
admit.  In  cases  where  morphia  fails,  atropia  may  be  tried,  in  doses  commencing  at  one- 
sixth  of  a  grain.  The  injection  of  a  less  quantity  than  this  would  probably  be  useless  in 
severe  tic. 

Hopeless  as  was  the  cure  of  this  form  of  neuralgia  under  Trousseau's  plan,  or  any 
other  which  might  be  directed  to  the  object  of  deeply  narcotizing  the  patient,  the  pros- 
pect is  by  no  means  so  cheerless  when  the  subcutaneous  injection  is  employed,  with  the 
precautions  above  mentioned.  Although  Dr.  Anstie  cannot  say  that  he  has  ever  seen  a 
positive  and  complete  cure  of  a  facial  neuralgia  setting  in  under  the  conditions  which 
have  been  described  as  peculiar  to  this  disease,  it  is  certain  that  the  experience  of  those 
who  have  used  the  subcutaneous  method  extensively  has  proved  that  the  attacks  may  be 
kept  at  bay,  and  their  severity  greatly  mitigated  when  they  occur ;  witii  this  general  re- 
sult, that  the  setting  in  of  a  facial  tic  in  the  later  period  of  life,  even  in  a  patient  whose 
family  and  constitutional  history  is  of  the  worst  augury,  is  no  longer  a  fatal  warning  of 
life-long  and  scarce  endurable  misery.  The  economy  in  the  necessary  use  of  opium 
effected  by  the  use  of  hypodermic  rather  than  gastric  administration  is  enormous ;  and 
this  not  merely  for  the  purpose  of  producing  a  given  effect  by  a  single  dose,  but  also 


5l8  PSYCHOLOGICAL    MEDICINE. 

(which  is  most  important  in  regard  to  the  preservation  of  digestion  and  nutrition)  with 
regard  to  the  rate  of  increase  in  the  doses. 

In  the  above  remarks  reference  has  only  been  had  to  those  modes  of  treatment  which 
are  within  the  reach  of  every  practitioner.  It  is  necessary  to  state,  however,  that  for 
those  who  are  so  circumstanced  as  to  be  able  to  provide  themselves  with  proper  apparatus 
for  the  generation  of  a  constant  galvanic  current,  the  prospects  of  effecting  good  in  even 
the  most  seemingly  hopeless  cases  of  spasmodic  facial  tic  are  very  greatly  increased.  It 
is  impossible  for  any  candid  person  to  study  carefully  the  treatise  of  Benedikt  without 
coming  to  the  conclusion  that  we  have  in  the  constant  current  a  remedy  capable  of  effect- 
ing much  more,  in  these  severe  cases,  than  any  treatment  by  drugs,  or  any  other  means. 
A  low-tension  current  from  a  Daniell's  batcery  (using  from  five  to  fifteen  cells,  according 
to  circumstances)  applied  daily  in  seances  of  a  few  minutes,  appears  sometimes  to  entirely 
arrest  facial  neuralgia  of  the  worst  type,  and  commencing  under  the  most  unfavorable 
omens.  Especially  may  we  indulge  hope,  as  it  seems  to  me,  in  regard  to  the  results  which 
may  be  obtained  from  the  galvanization  of  the  sympathetic,  in  cases  which  would  other- 
wise afford  no  rational  hopes  of  more  than  the  most  trifling  amendment.  Any  very  con- 
densed account  of  this  mode  of  treatment  would  be  likely  to  mislead.  To  those  who 
possess  the  requisite  preliminary  knowledge  of  electricity  and  electro-physiology,  and  also 
the  opportunities  of  providing  themselves  with  the  somewhat  expensive  and  troublesome 
luxury  of  a  really  effective  constant  battery,  our  author  urges 'the  necessity  of  a  careful 
study  of  the  English  treatise  of  Althaus,  and  the  German  treatises  of  Remak,  Benedikt, 
and  Meyer,  upon  the  medical  uses  of  electricity.  They  will  find  facts  therein  which  will 
at  once  arrest  their  attention,  and  engage  them  seriously  in  a  most  important  branch  of  the 
therapeutics  of  nerve-pain. 


CHAPTER   XXIX. 


LOCOMOTOR  ATAXIA,  CEREBRAL  HYPER^EMIA,  CEREBRAL  SOFTENING, 
AND  CEREBRAL  SCLEROSIS. 

Locomotor  ataxia,  or  posterior  spinal  sclerosis,  is  a  disease  of  the 
nervous  system,  characterized  in  its  inception  by  paroxysmal  wander- 
ing "  lightning  pains;"  by  a  diminution  of  the  patellar  tendon  reflex, 
so  that,  if  a  quick  tap  is  made  midway  between  the  lower  end  of  the 
patella  and  the  tuberosity  of  the  tibia,  the  quadriceps  extensor 
femoris  does  not  contract  as  it  does  normally,  and  we  get  no  jerk  of 
the  leg  as  we  should  do ;  by  diminution  of  the  vesical  and  rectal 
reflexes,  so  that  both  micturition  and  defecation  are  impaired;  im- 
pairment of  the  pupillary  reflex,  paralysis  of  the  ocular  muscles,  and 
incoordination  of  the  muscles.  There  is  also  plantar  anaesthesia. 
The  incoordination  of  movement   is   frequently   so   great  that  the 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.      519 

patient  cannot  walk  without  assistance.  We  may  also  find  in  loco- 
motor ataxia  the  crises  gastriques  of  Charcot,  attacks  in  which  there 
is  pain  in  the  stomach  and  chest,  with  continual  retching  and  vomit- 
ing- occurring  at  irregular  intervals.  There  is  apt  to  be  distension, 
with  pain  in  the  stomach,  and  griping  and  flatulent  eructations.  To 
recapitulate,  these  patients  have  a  staggering  gait,  diplopia,  inability 
to  stand  with  the  eyes  shut ;  pupils  insensitive  to  light,  and  analgesia 
of  the  extremities.  There  is  a  peculiar  arthropathy,  or  osteo-arthritic 
change,  apt  to  occur  in  locom.otor  ataxia,  in  which  we  meet  with 
great  disorganizations  of  certain  joints  and  spontaneous  fractures, 
owing  to  an  alteration  of  nutrition  in  the  osseous  tissue,  dependent 
upon  an  influence  of  the  nervous  system.  There  is  also  an  extremely 
rapid  wearing  away  of  the  articular  extremities. 

This  extremely  interesting  subject  of  the  osseous  and  articular 
lesions  of  locomotor  ataxia  has  as  yet  received  very  little  attention 
except  from  Dr.  Charcot,  of  Paris.  In  this  condition  of  the  wearing 
away  of  the  articular  extremities  of  the  long  bones  they  can  be 
knocked  together  audibly  and  without  pain.  There  may  be  also 
extensive  painless  swellings  of  the  joints,  not  confined  to  the  joints, 
but  extending  down  the  long  axis  of  the  limb.  As  a  result  of  the 
erosion  and  absorption  of  the  head  and  neck  of  bones  dislocations 
frequently  occur.  These  spontaneous  fractures  generally  take  place 
while  the  patient  is  walking  or  making  slight  movements.  There 
maybe  great  distension  of  joints,  with  relaxation  of  the  ligaments 
and  deformities  from  the  removal  of  natural  eminences  and  the  deposit 
of  masses  of  the  bone.  These  arthritic  changes  are  neurotic,  and 
are  essentially  different  from  those  of  chronic  rheumatic  or  osteo- 
arthritis, which  attacks  the  larger  in  preference  to  the  smaller  joints. 
The  fluid  effused  is  of  great  quantity,  and  not  limited  to  the  joint, 
but,  as  I  have  said,  expands  underneath  the  muscles  extending  down 
the  long  axis  of  the  limbs.  The  head  of  a  bone  in  ataxic  arthrop- 
athy is  destroyed  with  great  rapidity.  The  synovial  membrane  and 
•  .bone  are  alike  affected.  The  incoordination  of  this  disease  is  prob- 
ably to  be  accounted  for  by  the  inequality  of  tonicity  of  different 
groups  of  muscles,  and  also  the  loss  of  the  muscular  sense.  It  may, 
perhaps,  be  partly  due  to  a  limited  muscular  paralysis.  Respecting 
the  therapeutics  of  this  disease,  we  have  as  yet  failed  in  classing  it 
among  the  curable  affections  of  the  nervous  system,  although  there 
are  a  few  cases  on  record  of  cure.  Personally  I  have  obtained  great 
relief  from  the  use  of  the  constant  current  of  electricity — galvanic 


520  PSYCHOLOGICAL    MEDICINE. 

current — using  the  negative  pole  at  the  sacrum,  and  rubbing  the 
positive  pole,  to  which  is  attached  a  sponge  electrode  up  and  down 
the  spine,  and  on  either  side  of  the  sixth  and  seventh  cervical  ver- 
tebrae, so  as  to  quiet  the  irritation  of  the  posterior  roots.  I  think 
in  one  case,  by  counter-irritation,  by  small  fly-blisters  along  the. 
course  of  the  spine,  by  the  constant  current  applied  as  I  have  de- 
scribed, and  by  the  use  of  the  chloro-phosphide  of  arsenic — Routh's 
formula — in  5-minim  doses,  thrice  daily,  I  succeeded  in  curing  one 
case  in  its  incipient  stage,  making  my  patient  use  crutches.  I  also 
gave  cod-liver  oil  freely,  and  the  patient  was  made  to  rest  as  much 
as  possible.  The  nutrition  of  the  spinal  cord  was  markedly  increased 
by  these  means.  In  my  case  there  was  no  incoordination,  and  no 
loss  of  the  pupillary  reflex,  but  the  patellar  tendon  reflex  was  much 
diminished,  and  the  lightning  pains  and  partial  amaurosis  were  pre- 
sent. I  think  if  we  could  see  this  disease  in  its  incipient  stage,  which 
we  seldom  do,  that  we  might  hope,  by  appropriate  treatment,  for 
better  results  than  we  generally  obtain.  To  relieve  the  pains,  both 
the  galvanic  and  faradic  currents  are  sometimes  very  useful,  as  are 
also  the  hypodermics  of  morphia,  and  sometimes  chloroform  locally, 
a  lock  of  cotton  being  saturated  with  it  and  placed  under  a  watch- 
glass  on  the  affected  part.  The  tribasic  phosphate  of  silver  has  lately 
been  recommended  by  Dr.  Allan  McLean  Hamilton  as  a  remedy,  in 
^-grain  doses,  with  the  effect,  it  is  claimed,  of  relieving  pain  and  in- 
coordination.* 

Nerve-stretching  is  also,  I  think,  destined  to  play  an  important 
part  in  relieving  the  terrible  lightning  pains  of  locomotor  ataxia.  I 
think  that  the  incessant  pains,  which  undergo  exacerbations,  can  be 

*  Dr.  J.  Lockhart  Clarke  speaking  of  the  prognosis  and  treatment  of  this  disease  says, 
that  the  prognosis  is  generally  very  unfavorable.  An  early  diagnosis  is  of  the  greatest 
importance,  as  it  is  chiefly  at  the  first  invasion  of  the  disease  that  the  patient  is  most 
benefited  by  treatment.  An  important  object  is  to  protect  the  patient  from  cold  and  wet 
and  keep  him  in  an  equable  temperature.  The  whole  of  the  body  should  therefore  be 
enveloped  in  flannel.  A  good  and  generous  diet,  with  wine  or  beer,  seems  best  suited 
for  the  patient.  Of  the  diff"erent  medicines  that  have  been  used,  nitrate  of  silver  seems 
to  have  the  most  specific  influence  on  locomotor  ataxy,  -^th  of  a  grain  gradually  increased 
to  one  grain  three  times  a  day,  after  meals,  is  the  best  mode  of  exhibition.  If  it  should 
irritate  the  bowels  or  bladder,  it  may  be  combined  with  morphia,  cannabis  indica,  or  bel- 
ladonna. The  oxide  of  silver  is  a  useful  substitute  for  the  nitrate,  when  the  latter  dis- 
agrees. Dry  cupping  along  the  spine  has  been  found  useful.  For  the  relief  of  the  severe 
limb-pains  there  is  nothing  so  efficacious  as  the  subcutaneous  injection  of  morphia.  Dr. 
Clarke  has  always  found  that  constipation  aggravated  the  pains.  He  recommends  cod- 
liver  oil,  phosphorus,  rest  and  the  constant  or  galvanic  current  of  electricity. 


LOCOMOTOR   ATAXIA CEREBRAL    HYPER.EMIA,    ETC,  52  I 

very  much  relieved,  and  that  after  either  the  sciatic,  crural,  me- 
dian, or  radial  nerves  are  reached  by  incision,  they  should  be  lifted 
about  two  inches,  as,  by  M.  Gillette's  operation,  recently  performed 
in  Paris  on  M.  Debore's  patient,  the  traction  on  the  nerve  being 
made  in  a  line  perpendicular  to  the  axis  of  the  nerve.  There  is  no 
fear  .of  injuring  the  nerve,  and  experience  teaches  that  the  incoordi- 
nation is  greatly  improved,  and  that  immense  relief  to  the  pains  is 
afforded,  and  they  may  even  entirely  cease.  I  would  insist  on  the  fact, 
and  Dr.  Radcliffe,  of  London,  also  advances  it  in  his  writings  that, 
in  some  cases  of  locomotor  ataxia,  we  may  get  a  very  decided  amend- 
ment in  the  symptoms  of  the  disease.  The  disease  is  generally,  I 
think,  confined  to  the  lumbo-dorsal  portion  of  the  cord,  and  rarely 
ascends  so  as  to  implicate  the  cervical  portion  of  the  cord.  Loco- 
motor ataxia  may  be  distinguished  from  common  chronic  paraplegia 
by  the  fact  that  in  the  former  disease  there  is  no  true  paralysis  either 
in  the  lower  extremities  or  anywhere  else.  The  gait  is  also  very 
different, — in  locomotor  ataxia  the  heels  come  down  at  each  step 
with  a  stamp,  while  in  paraplegia  the  toes,  as  a  rule,  touch  the  ground 
first;  and  the  gait,  instead  of  being  precipitate  and  staggering,  is 
difficult  and  slow.  The  frequent  impairment  in  sight  or  hearing,  the 
strabismus  or  ptosis,  injection  of  the  conjunctiva,  and  the  character- 
istic neuralgic  pains  of  a  boring  and  shooting  character,  are  not 
found  in  chronic  paraplegia.  In  diseases  of  the  cerebellum,  although 
we  find  a  reeling  and  rolling  gait,  we  do  not  notice  the  precipitate, 
staggering  gait  of  locomotor  ataxia ;  neither  do  the  heels  come  down 
with  a  stamp.  If  a  careful  examination  is  made,  I  see  no  opportu- 
nity for  a  careful  physician  to  make  a  mistake  in  the  diagnosis  of 
this  disease. 

It  is  of  great  importance  that  an  early  diagnosis  be  made  in  this 
disease  if  we  are  to  get  better  results  from  treatment  than  formerly. 
We  should  remember,  therefore,  that  we  have  in  the  first  or  pre- 
monitory stage  of  locomotor  ataxia,  paroxysms  of  pain  of  a  neural- 
gic character,  wandering,  and  of  a  stabbing,  boring  nature,  generally 
in  the  feet  and  legs,  a  diminution  of  the  patellar  tendon,  vesical,  rectal, 
and  pupillary  reflexes,  numbness  in  the  feet  and  legs,  a  plantar  anaes- 
thesia more  particularly. 

As  the  disease  progresses,  we  see  the  peculiar  gait  and  the  char- 
acteristic incoordination  of  movement,  so  that  the  patient  is  obliged 
to  use  a  stick  in  walking;  strabismus,  ptosis,  injection  of  the  con- 
junctiva and  perhaps   contracted  pupils,  and  in  some   cases    some 


522  PSYCHOLOGICAL   MEDICINE. 

mental  impairment,  although  this,  I  think  I  am  right  in  saying,  is 
rather  a  rare  symptom.  Dr.  Rumpf,  of  Dusseldorf,  has  exhibited  to 
his  medical  society  a  typical  case  of  locomotor  ataxia  beginning  with 
shooting  pains  in  the  legs,  then  weakness  in  walking,  abnormal  sen- 
sation in  the  feet  and  hands,  tightness  around  the  waist,  and  weakness 
of  the  bladder,  passing  at  last  into  ataxia  of  the  upper  and  lower 
extremities,  with  muscular  force  little  impaired,  but  diminished  sen- 
sation of  the  whole  body,  both  to  impressions  of  touch  and  heat  and 
cold.  Dr.  Rumpf  first  saw  the  man,  who  was  40  years  of  age,  on 
the  29th  of  July,  and  on  the  29th  of  September  following  he  was 
quite  relieved  and  able  for  work.  The  only  treatment  used  was  the 
interrupted  current, — the  positive  pole  applied  to  the  sternum  and  the 
electrode  of  the  negative  pole  applied  to  the  back  and  down  the  ex- 
tremities. The  strength  of  the  current  was  strong  enough  when 
applied  to  the  median  nerve  to  cause  convulsions  (by  which  is  prob- 
ably meant  powerful  contractions).  The  applications  were  ten  min- 
utes long  and  every  other  day.  The  improvement  began  at  once. 
The  pains  disappeared,  the  sensibility  returned,  and  the  feeling  of 
tightness  disappeared  also.  The  galvanic  current  was  used  at  the 
beginning  of  September,  alternating  with  the  faradic.  This  case  was 
reported  in  the  jfoiirnal  of  Mental  Science  of  July,  1882. 

Dr.  Buzzard,  of  London,  has  exhibited  to  the  Pathological  Society 
of  London  three  typical  cases  suffering  from  osseous  and  articular 
lesions  in  the  course  of  locomotor  ataxia.  The  first  of  these  was 
a  man  in  whom  the  right  hip-joint  was  completely  disorganized,  the 
head  and  neck  of  the  femur  having  entirely  disappeared  within  about 
three  months.  The  second  case  was  a  woman  of  50  years  of  age, 
who  was  a  patient  of  the  National  Hospital  for  the  Paralyzed  and 
Epileptic.  This  patient  had  suffered  for  about  eleven  years  from 
tj'pical  "  lightning  "  pains  in  her  legs  and  arms,  and  had  been  affected 
for  about  the  same  time  with  attacks  of  the  crises  gastriqiies  of  Char- 
cot,— attacks  in  which  there  is  pain  in  the  stomach  and  chest,  with 
continual  retching  and  vomiting,  occurring  at  irregular  intervals,  some- 
times as  many  as  four  in  four  months,  the  longest  period  of  exemption 
having  been  eight  months.  The  other  symptoms  she  exhibited  were 
an  ataxic  gait,  very  small  pupils  not  reacting  to  light,  analgesia  of 
extremities,  defective  muscular  sense,  and  absence  of  patellar  tendon 
reflex.  One  day,  while  walking  along  her  ward  in  hospital,  her  right 
femur  fractured  through  its  neck.  About  one  year  later,  while  vom- 
iting in  bed,  her  left  hip-joint  suddenly  "  bulged  out."     Since  then 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.      523 

she  has  been  unable  to  use  either  leg.  Upon  careful  examination 
the  movements  of  both  hip-joints  were  found  free,  but  limited  in 
some  directions,  with  crepitation  more  marked  in  the  right  than  in 
the  left.  On  the  right  side  the  top  of  the  great  trochanter  was  nearly- 
level  with  the  anterior  superior  spinous  process,  and  on  the  left  the 
trochanter  is  extremely  prominent  and  the  bone  enlarged.  The 
conditions  observed  might  be  due,  it  was  thought,  either  to  spon- 
taneous fracture  of  the  neck  of  the  bone  on  each  side,  or  to  complete 
disorganization  of  the  joint,  with  atropic  changes  and  absorption  of 
the  neck  and  head  of  the  bone  on  the  right  side,  and  similar  changes 
on  the  left,  associated  with  enlargement  of  the  great  trochanter  from 
throwing  out  of  new  bone. 

The  third  case  was  that  of  a  woman  of  36,  married,  and  an  out- 
patient of  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 
She  had  been  a  patient  of  Professor  Henry  Smith's  in  the  King's 
College  Hospital.  This  patient  had  for  ten  years  been  subject  not 
only  to  the  typical  lightning  pains  in  her  extremities,  recurring  at 
intervals  of  a  month  or  two  and  lasting  three  or  four  days,  but  also 
had  had  very  characteristic  crises  gastriqiies.  These  had  occurred  at 
irregular  intervals,  between  which  she  had  felt  quite  well.  She  had 
never  passed  six  months  without  an  attack.  She  had  distension, 
pain,  vomiting,  and  retching  and  griping,  and  flatulent  eructations, 
recurring  daily  for  weeks  at  a  time.  Her  other  symptoms  were  stag- 
gering gait,  diplopia,  inability  to  stand  with  eyes  shut,  partial  color- 
blindness, pupils  insensitive  to  light,  and  analgesia  of  extremities. 
Three  years  ago  her  right  leg  became  red  and  swollen,  but  not  pain- 
ful, and  these  symptoms  subsided  under  rest.  In  June,  1878,  they 
recurred,  and  in  September  the  swelling  had  gone  down,  but  the 
knee-joint  was  useless.  At  the  same  time,  the  left  leg  began  to  swell, 
and  was  larger  than  natural  when  she  was  admitted  into  King's  College 
Hospital  at  the  end  of  the  year.  At  that  time  the  right  knee-joint 
was  found  to  be  disorganized.  There  was  grating,  but  no  pains  on 
moving  the  ends  of  the  bones.  The  internal  condyle  was  enlarged, 
and  projected  inwards.  The  external  condyle  could  not  be  felt.  The 
patella  rested  on  the  outer  surface  of  the  lower  end  of  the  femur, 
the  ligamentum  patellae  being  wasted.  There  was  fluctuation  in  the 
joint.  The  left  leg  was  swollen,  and  this  knee-joint,  which  was  ap- 
parently not  affected  on  admission,  became  enlarged,  and  the  leg 
dislocated  outwards  and  backwards  during  the  patient's  stay  of  one 
month  in  the  hospital.     The  muscles  of  the  lower  extremities  were 


524  PSYCHOLOGICAL    MEDICINE. 

wasted.  She  was  discharged  at  the  end  of  January  with  leather 
supports  to  each  knee,  which  enable  her  to  move  about  with  help. 
There  has  since  been  swelling  and  crepitation  of  the  right  shoulder- 
joint.  At  the  last  report,  it  felt  as  though  all  ligamentous  connec- 
tions had  disappeared  from  the  right  knee-joint.  The  ends  of  the 
bones  could  not  be  brought  into  apposition,  and  they  were  so  loosely 
connected  that  the  patient,  before  she  put  on  the  leather  casing,  had 
to  splice  them  together  with  a  bandage.  They  can  be  knocked  to- 
gether audibly,  and  without  pain.  It  seemed  as  though  the  condyles 
had  been  levelled  off  and  the  end  of  the  femur  turned  into  a  rounded 
and  smooth  stump,  whilst  the  upper  end  of  the  tibia  is  bevelled  off 
inwards.  The  patella  lies  two  inches  above  and  to  the  outside  of  the 
end  of  the  femur.  Along  the  outer  side  of  the  inner  hamstring  was 
a  firm,  smooth,  rounded  mass,  one  inch  by  half  an  inch.  On  the  left 
side  the  tibia  and  fibula  were  dislocated  backwards  and  slightly  out- 
wards. The  condyles  were  rounded  off,  the  inner  one  being  enlarged. 
The  patella  lay  over  the  end  of  the  femur  in  front. 

These  are  very  rare  and  interesting  cases,  and  I  am  indebted  for 
them  to  the  Report  of  the  Pathological  Society  of  London,  of  which  J. 
Hutchinson  has  been  the  president.  Charcot  first  described  this  ar- 
thropathy occurring  in  tabes  about  fourteen  years  ago,  but  little 
attention  has  been  paid  to  it  here. 

The  first  case  described  in  England  was  one  by  Clifford  Allbutt, 
in  1869.  The  second  one  was  reported  by  Dr.  Buzzard,  of  London, 
in  \}i\Q  Lancet  oi  1874.  In  France,  cases  have  been  described  by 
Vulpian,  Richet,  Dubois,  Bourneville,  Voisin,  Bourceret,  and  Tala- 
mon.  The  great  disorganization  of  some  of  the  joints,  and  the  mul- 
tiple spontaneous  fractures,  depend  primarily  upon  an  alteration  in 
the  nutrition  of  the  bone,  dependent  upon  nervous  influence,  and  are 
in  themselves  secondary  to  this  faulty  osseous  nutrition.  The  very 
rapid  erosion  and  absorption  of  the  ends  of  the  bones  is  very  dis- 
tinctive. 

Dr.  Buzzard,  of  London,  has  suggested  that,  as  the  gastric  symp- 
toms might,  with  some  confidence,  be  ascribed  to  sclerosal  invasion 
of  the  roots  of  the  vagus,  very  probably  a  change  in  some  structure 
contiguous  to  these  in  the  medulla  oblongata  might  be  discovered 
to  be  the  lesion  giving  rise  to  the  altered  nutrition  in  the  osseous 
system. 

Charcot,  of  Paris,  had  one  case  of  a  patient  suffering  from  loco- 
motor ataxia,  in  whom  the  head  of  the  humerus,  apparently  unaltered 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.       525 

in  shape,  was  displaced  under  the  clavicle,  and  projected  strongly 
under  the  skin ;  the  bone  was  quite  loose,  with  free  and  painless 
mobility.  The  opposite  humerus  was  dislocated  on  to  the  dorsum 
of  the  scapula,  and  one  knee  was  dislocated,  the  tibia  and  fibula  being 
twisted  and  displaced  up  behind  the  femur,  which  was  deformed  from 
the  loss  of  its  outer  condyle.  In  all  these  joints  there  was,  accord- 
ing to  Professor  Charcot,  remarkable  freedom  of  mobility  and  absence 
of  pain,  and  the  femur  was  greatly  altered  in  form. 

Respecting  progressive  locomotor  ataxy,  Dr.  C.  B.  Radcliffe,  Phys- 
ician to  the  Westminster  Hospital,  and  to  the  National  Hospital  for 
Paralysis  and  Epilepsy,  etc.,  says  : 

This  malady  was  discovered  seven  or  eight  years  ago  by  M.  Duchenne  (de  Boulogne), 
and  described  under  the  name  of  ataxic  locomotrice  progressive.  In  it  there  is  no  de- 
ficient action  of  the  will  upon  the  muscles  individually,  and  no  loss  of  muscular  force 
or  change  of  muscular  structure ;  but  there  is  deficient  action  in  that  involuntary  in- 
stinctive coordinating  power  by  which  various  groups  of  muscles  are  made  to  work  har- 
moniously together  in  such  acts  as  standing,  walking,  or  handling.  The  term  ataxy  (o, 
primitive,  and  Ta\Li,  order),  which  has  reference  to  the  deficiency  in  proper  coordinating 
power,  is  not  very  fortunate,  for  the  adjective  ataxic  is  very  commonly  used  in  a  different 
sense,  as  in  ataxic  fever,  where  what  is  meant  is  low  fever,  in  which  nervous  exhaustion 
is  the  predominant  condition.  To  meet  this  difficulty  other  names  have  been  suggested, 
but  the  satisfactory  name  has  yet  to  be  found,  and  for  the  present,  therefore,  we  must  be 
content  to  use  the  one  employed  originally,  and  call  the  disease  in  question  ataxic  loco- 
motrice progressive,  or  progressive  locomotor  ataxy,  or  ataxy  simply. 

Until  M.  Duchenne  (de  Boulogne)  drew  attention  to  it,  ataxy  was  confounded  with 
spinal  paralysis  in  general,  and  especially  with  that  vague  form  of  this  paralysis  which  is 
known  under  the  name  of  tabes  dorsalis.  The  disorderly  movements  of  the  muscles  were 
regarded  as  symptoms  of  paralysis..  It  was  not  perceived  that  the  muscles  in  which  these 
disorderly  movements  were  manifested  were  healthy,  and  behaved  well  in  all  respects  ex- 
cept when  they  were  called  upon  to  act  in  concert.  Moreover,  it  was  not  known  that 
this  loss  of  coordinating  muscular  power  simply  was  associated  with  other  symptoms  in 
a  definite  category.  In  a  word,  to  M.  Duchenne  (de  Boulogne)  must  undoubtedly  be 
ascribed  the  honor  which  belongs  to  him  who  discovers  a  disease,  sufficiently  definite  in 
its  character,  which  had  been  confounded  previously  with  other  and  very  dissimilar  dis- 
eases. 

The  case  which  serves  me  for  a  text  is  now  in  the  wards.  It  is  that  of  J.  C,  a  sailor, 
thirty-four  years  of  age,  living  at  Islington,  and  admitted  into  the  National  Hospital  for 
Paralysis  and  Epilepsy,  on  the  3d  of  April,  1865.     The  notes  I  have  run  thus : 

Present  Conditio7t. — J.  C.  is  a  man  somewliat  under  the  average  height  and  weight, 
well-proportioned,  well-developed  as  to  muscle,  especially  in  the  upper  parts  of  the  body, 
with  scarcely  any  subcutaneous  fat,  with  abundance  of  brown  hair  on  the  head  and  face, 
and  with  a  complexion  much  dried  and  browned  by  long  exposure  to  sun  and  sea. 

He  is  capable  of  walking  without  a  stick,  but  his  gait  is  peculiar — staggering,  precipi- 
tate, the  legs  thrown  about  vaguely  and  spasmodically,  and  the  heel  brought  down  with 
force  at  each  step.  With  his  eyes  shut,  or  in  the  dark,  he  reels  over  at  once,  and  would 
fall  helplessly  unless  prevented  from  doing  so.     In  the  sitting  posture  he  can  lift  either 


526  PSYCHOLOGICAL    MEDICINE. 

leg  steadily  into  any  position,  and  keep  it  there ;  and  when  the  leg  is  put  out  in  this  man- 
ner he  can  keep  it  extended,  in  spite  of  a  very  strong  effort  on  my  part  to  flex  it.  In 
order  to  this,  however,  he  must  see  what  he  is  doing,  for,  if  his  eyes  are  shut,  the  leg  at 
once  becomes  unsteady,  and  little  force,  comparatively,  is  required  to  bend  it.  The  right 
leg  is  a  little  weaker  than  the  left,  but  not  to  any  very  considerable  degree.  He  finds  it 
very  difficult  to  come  down  stairs,  or  to  quicken  his  pace  much,  and  he  is  speedily  fatigued 
by  the  acts  of  standing  or  walking.  On  being  told  to  shut  his  eyes,  and  touch  his  nose 
with  his  forefinger  of  each  hand  in  turn,  he  did  so  with  tolerable  accuracy,  especially 
with  the  forefinger  of  the  left  hand.  On  being  told  to  stretch  out  his  arms,  and  keep 
them  outj  he  did  so  quite  well,  but  only  so  long  as  he  was  allowed  to  see  what  he  was 
doing,  for  on  holding  a  book  before  his  eyes,  his  arms,  shoulders,  and  neck  and  head — 
the  upper  part  of  his  body  generally — at  once  became  affected  with  convulsive  titubation. 
When  the  book  was  taken  away  these  movements  speedily  came  to  an  end,  but  not  be- 
fore they  had  issued  in  a  fit  of  crying  and  sobbmg,  which  was  not  a  little  distressing  to 
witness.  This  fit  took  the  patient  quite  by  surprise ;  and  it  could  not  be  accounted  for 
by  the  examination  having  been  conducted  roughly,  or  carried  on  for  an  undue  length  of 
time;  indeed,  the  holding  of  the  book  before  the  eyes,  which  was  its  immediate  cause, 
did  not  occupy  more  than  a  minute  at  the  most. 

The  muscles  of  the  lower  limbs  generally  are  less  developed  than  those  of  the  upper 
limbs  and  trunk,  but  there  is  no  appearance  of  wasting  in  them.  Their  electro-contrac- 
tility is  perfect ;  they  stand  out  firm  and  hard  when  made  to  contract  by  the  will,  and  the 
contraction  seems  every  whit  as  strong  as  it  ought  to  be.  Indeed,  as  has  been  stated  al- 
ready, when  the  leg  is  put  out  and  stiffened,  it  is  not  in  my  power  to  bend  it  against  the 
will  of  the  patient,  except  by  the  exercise  of  great  force.  There  is  no  tremulousness 
anywhere ;  and  no  marked  reflex  movements  are  produced  by  tickling  the  soles  of  the 
feet. 

What  the  patient  complains  of  chiefly,  are  excruciating,  stabbing,  boring,  nipping  pangs 
of  pain,  flitting  from  one  spot  to  another  in  a  very  erratic  manner,  in  paroxysms  lasting 
from  a  few  minutes  to  twelve,  twenty-four,  or  forty-eight  hours ;  and  generally  fixing  upon 
one  spot  only  in  any  single  paroxysm.  These  pangs  are  most  frequently  felt  in  the  two 
feet,  especially  about  the  outer  side  of  the  metatarsal  bone  of  the  little  toe ;  they  are  also 
felt  not  unfrequently  at  the  back  of  the  thighs,  in  the  nates,  and  in  the  upper  arm  about 
the  lower  part  of  the  belly  of  the  biceps.  They  are  scarcely  ever  absent,  especially  at 
night;  at  night,  too,  there  is  often  a  sensation  of  great  coldness,  with  some  degree  of  con- 
striction, in  the  painful  parts. 

Measured  by  the  compasses,  tactile  sensibility  is  found  to  be  much  impaired  in  the  feet 
(especially  in  the  soles),  in  the  lower  halves  of  both  legs,  and  to  some  degree,  also,  in 
the  back  of  the  thighs,  in  the  nates,  and  in  the  palms  of  the  hands.  The  ground  is  felt 
veiy  obscurely,  but  so  far  as  it  is  felt  the  sensations'  are  accurate — that  is  to  say,  it  does 
not  seem  to  the  patient  as  if  there  were  elastic  cushions,  pebbles,  or  other  imaginary  bodies, 
or  as  if  there  was  nothing  at  all,  under  the  feet. 

Very  rough  pinching  is  scarcely  at  all  felt  in  the  benumbed  parts,  but  elsewhere  the 
sensibility  to  painful  impressions  is  keen  enough. 

In  the  benumbed  parts-,  also,  and  in  a  lesser  degree  in  some  other  parts,  muscular  sen- 
sibility (and  with  it  probably  the  proper  sensibility  of  the  joints  and  bones)  is  manifestly 
diminished.  In  bed,  for  example,  when  there  is  no  light,  J.  C.  says  that  he  cannot  clearly 
tell  where  his  feet  are,  and  that  not  unfrequently  his  legs  get  quite  out  of  bed  without  his 
knowledge.  There  is  also  very  little  feeling  of  pressure  when  the  muscles  of  the  feet  and 
legs  are  squeezed  with  considerable  force ;  and  in  the  arms,  as  well  as  in  the  legs,  the 
faculty  of  measuring  and  adjusting  the  amount  of  muscular  action  necessary  for  any  given 


LOCOMOTOR   ATAXIA CEREBRAL    HYPERiEMIA,    ETC.  52/ 

act  is  evidently  not  as  much  alive  as  it  should  be.  For  instance,  when  two  weights  are 
placed  in  his  hand,  one  after  the  other,  one  of  them  being  at  least  a  pound  heavier  than 
the  other,  he  finds  it  difficult  to  say  with  certainty  which  is  the  heavier  of  the  two. 

The  sight  of  each  eye  is  defective,  and  glasses  afford  no  relief.  The  pupils  are  equal 
in  size,  and  respond  fairly  to  the  light.  The  conjunctivas  are  injected.  There  is  no  arcus 
senilis.     There  is  no  squinting  or  ptosis. 

The  heai-ing  of  each  ear  is  so  dull  as  to  make  it  necessary  to  speak  in  a  very  loud  tone 
in  order  to  be  heard.  There  are  also  constant  singing  and  booming  noises  in  the  ears — 
"  almost  like  the  wind  in  the  shrouds,"  he  says. 

The  memory  is  bad,  the  spirits  are  very  despondent,  the  head  generally  "  feels  very 
heavy,"  and  of  late  (this  statement  is  volunteered  by  the  patientj  there  has  been  a  frequent 
temptation  to  commit  suicide. 

The  pulse  is  feeble,  and  about  70  in  the  minute.  The  appetite  is  good.  The  bowels 
are  somewhat  constipated.  In  any  case  a  long  time  is  spent  over  a  stool ;  "  it  won't  come 
out,"  is  the  patient's  own  description  of  the  trouble  in  this  quarter.  The  urine  is  also 
voided  slowly  and  with  difficulty,  although  the  urethra  is  free  from  stricture,  and  now 
and  then  it  escapes  in  bed  at  night.  Sexually,  the  state  may  be  spoken  of  as  approaching 
to,  if  not  amounting  to,  spermatorrhoea. 

Previous  History. — Five  years  ago  J.  C,  it  appears,  began  to  suffer  from  pains  in  the 
legs  and  back,  and  to  be  unsteady  in  his  gait ;  about  the  same  time,  also,  his  sight  and 
hearing  began  to  fail,  and  from  that  time  to  this  he  has  continued  to  get  gradually  worse 
and  worse.  Four  years  ago  he  had  a  sun-stroke  in  the  West  Indies,  of  which  the  imme- 
diate symptoms  were  violent  agitation  and  shaking,  without  loss  of  consciousness,  and 
for  which  he  was  taken  into  an  hospital  and  bled ;  but  this  accident  was  twelve  months 
after  his  present  malady  had  commenced,  and,  therefore,  it  is  not  possible  to  look  upon 
it  as  a  cause  of  this  malady. 

C.  was  at  sea  seventeen  years  in  all,  chiefly  in  hot  climates,  as  the  West  Indies  and 
West  Coast  of  Africa,  and  he  continued  at  sea  three  years  after  he  had  begun  to  suffer 
from  unsteadiness  of  gait  and  from  the  other  symptoms  which  have  just  been  mentioned. 
Once  during  the  time  he  was  at  sea  he  had  chancres,  without  secondary  symptoms,  and 
repeatedly  he  had  the  diarrhoea,  but,  with  these  exceptions,  his  health  on  all  occasions 
appears  to  have  been  very  good.  He  says  that  he  was  always  very  careless,  often  sleeping 
almost  without  clothes  upon  the  bare  deck  or  upon  the  ground,  and  that  he  was  always 
"  too  much  given  to  drink  and  women."  For  the  last  two  years  the  sexual  power  has  been 
much  damped ;  but  before  this  time,  according  to  his  own  showing,  he  appears  to  have 
been  little  better  than  a  very  satyr.  Two  years  ago,  when  obliged  to  abandon  his  calling 
as  a  sailor,  he  was  for  a  while  treated  in  the  hospital  at  Quebec  for  rheumatism.  After- 
wards he  found  his  way  to  this  country,  and  became  an  out-patient  first  at  one  hospital 
then  another.  During  this  time  he  appears  to  have  been  frequently  blistered  along  the 
spine,  and  on  one  occasion  to  have  been  salivated.  For  the  rest  I  have  only  to  add  that 
his  father  died  early  in  life  of  consumption,  that  his  mother  died  young  from  some  un- 
known chronic  disease,  and  that  a  brother,  the  only  member  of  the  family  besides  him- 
self, is  now  dying  of  the  disease  which  proved  fatal  to  his  father. 

M.  Duchenne,  whose  description  is  the  best  as  well  as  the  first,  marks  out  three  stages 
in  the  course  of  the  malady,  of  which  this  case  is  an  example.  In  the  first  stage,  the 
patient  suffers  from  paralysis,  often  temporary  only,  of  one  or  other  of  the  motor  nerves 
of  the  eye,  from  some  degree  of  amaurosis,  usually  accompanied  by  unequal  pupils,  and 
from  the  peculiar  boring,  erratic  pangs  of  pains  from  which  C.  suffered.  In  the  second 
stage,  in  addition  to  the  symptoms  of  the  first  stage,  the  characteristic  unsteadiness  of  gait 
begins  to  show  itself,  together  with  diminished  sensibility  to  touch  and  pain  in  the  skin 


528  PSYCHOLOGICAL   MEDICINE. 

of  the  lower  parts  of  the  legs,  in  the  skin  of  the  soles  of  the  feet  especially,  the  interval 
between  the  first  stage  and  the  second  varying  in  length  from  a  few  months  to  several 
years.  In  the  third  stage,  the  malady  becomes  more  profound  and  general,  the  disorder 
in  involuntary  coordinate  movement  increasing  in  the  legs  and  extending  to  the  upper 
parts  of  the  body,  the  anaesthesia  increasing  m  the  parts  first  affected  and  extending  to 
other  parts,  not  of  the  skin  only,  but  even  to  the  muscles,  joints,  and  bones.  M.  Duchenne 
does  not  consider  the  affections  of  the  bladder,  the  rectum,  and  the  genital  apparatus  as 
essential  symptoms  of  the  disease  in  any  one  of  these  three  stages ;  he  speaks  of  them  as 
"  epiphenomenes  "  only. 

So  far  as  it  goes,  the  history  of  C.  does  not  tally  with  this  division  of  the  disease  into 
stages,  for  in  it  the  failure  of  sight,  the  pains,  and  the  irregularity  of  instinctive  coordinate 
movement  are  seen  to  have  made  their  appearance  together.  Nor  is  this  history  altogether 
exceptional  in  this  respect;  and  therefore  the  only  conclusion  to  be  drawn  is  that  there 
are  some  cases,  perhaps  the  majority,  in  which  the  symptoms  admit  of  being  grouped  in 
the  three  stages  indicated  by  M.  Duchenne. 

In  the  majority  of  cases,  undoubtedly,  the  principal  symptoms  of  ataxy  agree  with  those 
which  are  met  with  in  C.'s  case.  There  is  the  same  irregularity  of  involuntary  coordinate 
movement  in  muscles  perfectly  healthy  in  other  respects,  the  same  peculiar  pains,  and  the 
same  anaesthesia.  Still  there  are  other  cases  in  which  the  pains  or  the  anaesthesia  are 
either  not  very  conspicuous  phenomena  or  else  absent  altogether.  Thus,  I  have  met 
with  four  cases  out  of  seven,  not  very  advanced  in  degree  it  is  true,  in  which  there  were 
no  pains  to  speak  of,  and  with  two  cases  (out  of  the  same  seven)  in  which  there  was  no 
anaesthesia.  In  the  majority  of  cases,  perhaps,  the  eyesight  fails  at  an  early  period,  and 
in  many  cases  this  failure  is  associated  with  some  paralysis,  often  transitory,  of  the  motor 
nerves,  one  or  other,  of  the  eye,  or  of  some  branches  of  the  motor  nerves  of  the  face ;  but 
there  are  other  cases  in  which  none  of  these  phenomena  are  present.  In  a  word,  the 
affections  of  the  bladder,  rectum,  and  genital  apparatus  are  not  the  only  features  which 
must  be  looked  upon  as  accidental,  as  "  epiphenomes;"  and  the  simple  truth  is,  that  the 
idea  of  the  disease  becomes  clearer  just  in  proportion  as  this  fact  is  clearly  realized. 

Ataxy,  it  is  said,  may  be  confounded  with  several  diseases,  especially  with  simple  loss 
of  muscular  sensibility,  with  disease  of  the  cerebellum,  with  general  paralysis  of  the  in- 
sane, with  general  spinal  paralysis  and  common  paraulegia,  with  saturnine  paralysis,  with 
Cruveilhier's  disease,  with  paralysis  agitans,  and  with  chorea  and  some  other  affections 
of  the  kind ;  but  fortunately,  as  a  rule,  very  little  attention  will  serve  to  prevent  such 
confusion. 

Simple  loss  of  "muscular  sense"  has  been  supposed  to  be  the  cause  of  ataxy,  and 
undoubtedly  this  is  a  malady  frequently  associated  with  ataxy,  and  most  easily  confounded 
with  it.  In  simple  loss  of  muscular  sense,  however,  the  sight  can  supply  what  is  lost ; 
and  thus,  when  the  eye  is  open  and  the  attention  alive,  the  involuntary  coordinate  move- 
ments, as  well  as  the  voluntary  movements  of  the  affected  muscles,  are  all  executed 
regularly. 

In  disease  of  the  cerebellum  there  appears,  at  first  sight,  to  be  the  same  disorder  in 
muscular  movements  as  in  ataxy,  but  this  similarity  is  deceptive.  There  is  now,  curiously, 
in  the  same  ward,  and  also  under  my  care,  a  boy  in  whom  there  appears  to  be  some 
congenital  defect  in  the  cerebellum,  want  of  due  development  probably.  This  boy  has 
had  a  very  peculiar  gait;  he  reels  and  rolls  about  in  walking  as  if  he  were  giddy  or 
drunk ;  there  is  nothing  peculiar  in  the  way  in  which  he  plants  his  feet ;  and  this  way 
of  walking  is  precisely  that  which  appears  to  me  more  or  less  characteristic  of  disease 
in  the  cerebellum.  In  ataxy,  on  the  other  hand,  the  gait,  as  has  been  said,  is  staggering, 
precipitate,  the  legs  thrown  about  vaguely  and  spasmodically,  and  the  heels  brought  down 


LOCOMOTOR    ATAXIA—CEREBRAL    HYPEREMIA,    ETC,  529 

with  force  at  each  step.  There  is  something  very  peculiar  in  the  way  in  which  the  feet 
are  planted  ;  the  gait  does  not  give  the  idea  of  giddiness;  there  appears  to  be  some  want 
of  balance  between  the  flexors  and  extensors  in  each  leg,  the  flexors  having  the  advantage ; 
and,  in  addition,  the  muscles,  when  they  act,  seem  to  contract  with  a  sort  of  jerk, — spas- 
modically. In  certain  diseases  of  the  cerebellum,  also,  other  symptoms  are  likely  to  be 
present  which  will  assist  in  the  formation  of  a  correct  diagnosis,  especially  violent  pains, 
augmented  by  movement,  in  one  or  other  part  of  the  head,  and  frequent  and  obstinate 
vomiting.  Moreover,  in  these  diseases  the  onset  is  generally  sudden,  and  the  progress 
uncomplicated  with  the  peculiar  pains  and  anaesthesia  of  ataxy  proper. 

In  general  paralysis  of  the  insane,  the  hesitation  in  speech,  the  tremulousness  of  the 
lips  and  tongue,  the  general  tremulousness,  the  true  paralytic  weakness  of  the  muscles  as 
to  voluntary  movement,  and  the  mental  condition  of  the  patient,  must  readily  serve  to 
prevent  the  unsteadiness  of  gait  and  other  evidences  of  disordered  co-ordinate  movement 
from  being  confounded  with  those  which  occur  in  ataxy ;  and  in  other  respects,  also,  the 
features  of  the  two  diseases  are  sufficiently  distinct. 

In  general  spinal  paralysis  and  in  common  paraplegia  there  is  true  paralysis,  more  or 
less  complete,  of  the  muscles  as  to  voluntary  power;  and  the  muscles,  moreover,  are 
much  damaged  as  to  their  nutrition  and  contractility,  and  generally  as  to  their  sensi- 
bility, too.  In  the  majority  of  cases,  also,  formication  is  associated  with  numbness,  and, 
what  has  never  yet  been  noticed  in  ataxy,  the  sensibility  to  difference  of  temperature  is 
much  impaired  or  altogether  lost  in  the  paralyzed  parts.  Vei'y  generally  there  is  tender- 
ness in  some  part  of  the  spine,  and  not  unfrequently  pain  in  the  same  region  or  in  the 
paralyzed  parts;  and,  if  there  be  pain,  it  is,  as  a  rule,  more  like  dull  rheumatic  aching 
than  like  the  peculiar  excruciating,  stabbing,  boring,  nipping  pangs  of  pain,  flitting  from 
one  spot  to  another  in  a  very  erratic  manner,  and  occurring  in  paroxysms  of  varying 
duration,  which  are  present  in  C.'s  case,  and  which  are  rarely  absent  in  cases  of  the 
kind.  And,  in  those  cases  where  progression  is  possible,  the  gait  is  almost  always  suffi- 
ciently characteristic — not  staggering,  precipitate — the  legs  thrown  about  vaguely  and 
spasmodically,  and  the  heel  brought  down  with  force  at  each  step,  as  in  C.'s  case  and  in 
other  cases  of  the  kind,  but  hampered  and  slow,  partly  from  want  of  voluntary  power 
over  the  legs,  and  partly  from  the  muscles  becoming  stiff  in  moving,  each  leg  being 
brought  forward  with  evident  difficulty,  even  with  the  help  of  an  upward  hitch  of  the 
whole  side  of  the  body  belonging  to  it,  and  the  part  of  the  foot  first  brought  in  contact 
with  the  ground  being  as  a  rule,  not  the  heel,  but  the  toes. 

In  saturnine  paralysis  it  is  the  voluntary  power  over  ceiiain  muscles  which  is  impaired 
and  gone,  and  the  muscles  are  atrophied  and  deprived  of  electric  contractility  when  the 
malady  has  reached  its  height.  Indeed,  it  is  difficult  to  understand  how  this  affection 
can  be  confounded  with  ataxy. 

In  Cruveilhier's  disease,  as  I  showed  in  a  former  lecture  {^Lancet,  January  i6,  1865), 
the  wasted  muscles  are  changed  in  great  measure  into  fat,  and,  as  it  were,  dissected  away, 
and  any  errors  in  movement  are  such  as  may  be  accounted  for  by  this  atrophy  and  ab- 
sence ;  whereas  in  ataxy  the  muscles  are  plump,  and  to  all  appearance  perfectly  healthy, 
and  the  errors  of  movement  are  those  which  refer  to  want  of  proper  involuntary  coordi- 
nating power.  Moreover,  in  Cruveilhier's  disease  the  pains  and  anaesthesia  of  ataxy  are 
not  met  with. 

In  chorea  there  is  great  want  of  coordinating  power  in  muscular  movement,  but  the 
rest  of  the  history  is  quite  different  from  that  of  ataxy,  so  different  and  so  well  known  as 
to  make  it  altogether  unnecessary  to  recall  it  to  your  memory.  And  so  likewise  in  regard 
to  those  other  affections  which  come  into  the  same  category  as  chorea. 

And  lastly,  in  paralysis  agitans  a  mistake  cannot  well  be  made,  for  the  general  features 

34 


530  PSYCHOLOGICAL   MEDICINE. 

of  the  disease  are  more  akin  to  those  which  are  present  in  general  paralysis  than  to  those 
which  are  characteristic  of  ataxy. 

In  some  cases  Duchenne's  disease  has  been  associated  with  other  diseases  of  the  nervous 
system,  as  with  Cruveilhier's  disease,  or  with  general  spinal  paralysis  or  common  para- 
plegia, and  in  these  cases  the  distinctive  characters  of  the  disorder  may  be  somewhat 
masked;  but  in  ordinary  cases  there  can  be  but  little  difficulty  in  arriving  at  a  correct 
diagnosis. 

The  pathology  of  ataxy  is  yet  in  its  infancy.  The  most  marked  change  detected  after 
death  as  yet  is  degeneration  and  disappearance,  more  or  less  complete,  of  the  posterior 
columns  and  of  the  posterior  roots  of  the  nerves  of  the  spinal  cord.  Mr.  Lockhart  Clarke 
has  shown  me  some  beautiful  microscopic  slides,  which  furnish  most  conclusive  proof  of 
this  fact.  But  I  am  not  prepared  to  think  that  these  are  the  only  changes  to  be  met  with. 
On  the  contrary,  I  fully  believe  that  corresponding  changes  will  eventually  be  found  in 
those  parts  of  the  cerebrum,  wherever  they  are,  which  have  specially  to  do  with  the  co- 
ordination of  muscular  movements. 

The  prognosis  is  full  of  gloom.  The  progress  of  bad  to  worse  may  be  slow,  very  slow, 
but  as  yet  there  is  too  much  reason  to  believe  that  the  term  "  progressive,"  in  the  sense, 
of  going  on  from  bad  to  worse,  is  not  misapplied.  Still  I  know  of  two  cases  which  jus- 
tify a  much  more  hopeful  opinion. 

The  treatment  in  C.'s  case  consists  in  good  food  and  rest,  in  hypophosphite  of  soda 
and  cod-liver  oil,  and  in  the  electrifying  of  the  region  of  the  cord  with  free  positive  elec- 
tricity, and  we  shall  see  in  time  whether  any  good  will  come  out  of  it.  I  am  not  very 
sanguine  ;  at  the  same  time  I  have  this  to  encourage  me — that  this  is  the  kind  of  treat- 
ment which  has  done  and  is  doing  good  in  the  two  cases  to  which  I  have  just  referred. 

Dr.  Julius  Althaus,  Physician  to  the  Royal  Infirmary  for  Diseases 
of  the  Chest,  City  Road,  says : 

[This  disease,  recently  described  by  French  physicians  as  progressive  locomotor  ataxy, 
was  first  described  more  than  thirty  years  ago  as  tabes  dorsalis,  yet  the  nature  of  the 
complaint  and  the  connection  which  exists  between  the  symptoms  manifested  during 
life  and  the  structural  changes  found  after  death  have,  until  quite  recently,  been  mis- 
understood.] 

Tabes  dorsalis  is  first  spoken  of  in  the  works  of  Hippocrates,  and  was  by  the  father  of 
medical  literature  believed  to  arise  from  excesses  in  sexual  intercourse,  the  chief  symp- 
toms of  the  disease  being  spermatorrhoea,  marasmus,  and  hectic  fever.  This  meaning  of 
the  term,  however,  has  gradually  changed,  and  those  authors  who  wrote  on  tabes  in  the 
first  decennia  of  this  century  understood  by  it  atrophy  of  the  posterior  portion  of  the  spinal 
cord,  brought  on,  not  merely  by  sexual  exhaustion,  but  also  by  exposure  to  wet,  rheuma- 
tism, gout,  and  other  causes,  the  chief  symptom  being  a  peculiar  form  of  paraplegia. 
The  disorder  was  chiefly  investigated  by  English  and  German  physicians,  such  as  Aber- 
crombie,  Hufeland,  Steinthal,  Romberg,  and  others.  Their  descriptions,  although  in 
some  instances  most  eloquent,  were,  however,  to  a  certain  extent,  wanting  in  accuracy, 
inasmuch  as  several  different  affections  of  the  cord  were  comprehended  under  the  name 
of  tabes,  and  a  clear  distinction  was  not  drawn  between  tabes  and  pai^aplegia.  It  was 
only  after  a  more  careful  clinical  study  of  the  symptoms  had  been  made,  and  after  patho- 
logical anatomy,  aided  by  the  microscope,  had  stepped  in,  that  a  peculiar  disease  of  itself, 
and  one  characterized  by  uniform  structural  lesions,  could  take  its  place  in  our  nosologi- 
cal system.  The  chief  credit  of  the  anatomical  investigations  is  due  to  Professors  Vir- 
chow,  Tiirck,  Rokitansky,  and  Leyden,  and  in  this  country  to  Dr.  Gull  and  Mr.  Lockhart 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.      53  I 

Clarke,  who  have  shown  that,  in  well-marked  cases  of  tabes,  an  actual  waste  of  nerve- 
fibres  of  the  posterior  columns  of  the  spinal  cord  takes  place,  together  with  the  formation 
of  amyloid  corpuscles  and  considerable  proliferation  of  connective  tissue. 

The  first  who  drew  a  distinction  between  this  disease  and  paralysis  was  Dr.  Todd.  He 
said  in  an  article  on  the  nervous  system  in  his  Cyclopcedia,  that  two  kinds  of  paralysis 
might  be  noticed  in  the  lower  extremities ;  the  one  consisting  simply  in  the  impairment 
or  loss  of  voluntary  motion ;  the  other  distinguished  by  a  diminution  or  total  absence  of 
the  power  of  co-ordinating  movements.  In  the  latter  form,  while  considerable  muscular 
power  remained,  the  patient  found  great  difficulty  in  walking,  and  his  gait  was  so  totter- 
ing and  uncertain  that  his  centre  of  gravity  was  easily  displaced.  In  these  few  words  we 
have  a  good  description  of  the  system  of  ataxy,  upon  which  lately  so  much  stress  has 
been  laid  by  French  physicians.  The  term  "  ataxy  "  is  as  old  as  that  of  "  tabes,"  for  it 
also  originated  with  Hippocrates ;  and  it  has  likewise  entirely  changed  its  meaning  in 
the  course  of  time.  Some  authors  have  applied  it  to  chorea,  others  to  fevers,  others  to 
various  nervous  disorders.  At  present,  however,  we  understand  by  ataxy,  not  a  disease 
of  itself,  but  merely  a  symptom  to  which  various  disorders  may  give  rise,  and  which  es- 
sentially consists  of  a  want  of  co-ordination  of  voluntary  movements,  and  a  tendency  on 
the  part  of  the  patient  to  lose  his  balance,  but  without  actual  loss  of  power,  and  apart 
from  tremor,  chorea,  and  paralysis.  This  symptom  may  be  observed  in  disease  of  the 
cerebellum,  and  in  poisoning  by  alcohol,  lead,  and  mercury;  but  it  is  more  especially 
connected  with  that  disease  which  has  been  long  familiar  to  us  as  tabes.  The  best  clinical 
study  of  this  symptom  we  owe  to  M.  Duchenne  de  Boulogne,  who,  from  1858  up  to  this 
time,  has  published  a  number  of  memoirs,  in  which  he  described  what  he  thought  to  be 
an  entirely  new  disease,  which  he  called  "progressive  locomotor  ataxy,"  and  which  he 
believed  to  be  a  functional  disorder  of  the  cerebellum.  His  apparent  discovery  was 
hailed  as  a  real  one  in  P'rance,  and  Professor  Trousseau  actually  proposed  to  call  the 
new  stranger  "  Duchenne's  disease;"  but,  on  looking  more  closely  into  the  matter,  we 
find  that  Duchenne's  description  is  altogether  applicable  to  our  old  friend,  tabes.  I  have 
not  the  slightest  hesitation  in  acknowledging  the  great  ability  and  originality  of  M.  Du- 
chenne's researches,  which  were  perhaps  more  strikingly  displayed  in  this  case  just  on 
account  of  his  being  unacquainted  with  the  previous  literature  on  the  subject ;  yet,  if  I 
thought  it  desirable  to  attach  a  proper  name  to  this  affection,  I  should  prefer  calling  it 
"  Todd's  disease,"  as  Todd  first  drew  the  distinction  between  ataxy  and  paralysis  eleven 
years  previous  to  Duchenne.  But  the  best  plan  is,  perhaps  merely  to  drop  the  term 
"  tabes,"'  as  being  too  vague,  and  to  call  the  disease  under  consideration  "  progressive 
locomotor  ataxy,  or  wasting  of  the  posterior  columns  of  the  spinal  cord." 

The  following  details  of  a  case  of  this  affection,  which  I  have  had  under  my  obser- 
vation for  about  five  years,  are  well  suited  to  illustrate  the  symptoms  and  progress  of  the 
disease : 

R.  B.,  a  commercial  traveller,  aged  37,  a  tall  and  rather  spare  man,  with  a  sallow 
complexion,  first  consulted  me  in  February,  i860,  when  he  gave  me  the  following  his- 
tory. His  mother  had  always  beeia  healthy,  but  his  father  had  for  the  greater  part  of  his 
life  suffered  from  epilepsy,  and  died  in  a  fit.  The  patient  was  brought  up  to  the  law; 
but  in  consequence  of  a  disappointment  he  left  that  profession,  and  enlisted  as  a  soldier. 
He  served  in  Australia  and  Canada,  and  during  that  time  suffered  much  from  rheuma- 
tism. He  never  exceeded  in  drinking,  but  occasionally  in  sexual  intercourse.  He  twice 
had  gonorrhoea,  but  no  syphilis.  He  suffered  for  a  long  time  from  haemorrhoids,  for 
which,  in  1855,  he  underwent  the  operation  by  ligature,  and  he  ascribed  the  commence- 
ment of  his  present  illness  to  that  operation,  saying  that  he  never  felt  quite  the  same  man 
after  the  hsemorrhoidal  flow  had  ceased.     He  left  the  army  in  1856,  and  married.     He  is 


532  PSYCHOLOGICAL    MEDICINE. 

now  father  of  a  healthy  child.  For  the  last  eighteen  months  he  has  been  a  commercial 
traveller,  and  as  such  he  is  always  on  the  move,  and  frequently  exposed  to  cold,  damp, 
and  great  fatigues.  In  January,  1857,  he  first  noticed  that  his  sight  became  weak,  and 
he  had  some  difficulty  in  writing  and  reading  small  prints.  Soon  after  he  felt  pains  of  a 
peculiar  character,  which  he  described  as  electric  shocks  through  the  legs,  and  as  if  the 
muscles  were  being  rent  asunder.  These  shocks  came  every  two  or  three  minutes.  He 
underwent  treatment  by  liniments  and  other  external  applications,  but  without  relief. 
His  gait  now  became  tottering,  and  he  had  considerable  difficulty  in  walking.  He  never 
goes  out  without  a  stick,  and  sometimes  he  is  obliged  to  use  two.  In  the  summer  of  1859 
he  consulted  the  late  Dr.  Todd,  who  told  him  that  his  case  was  incurable,  and  that  he 
would  have  to  be  on  the  sofa  for  the  rest  of  his  life.  He  prescribed  strychnine  and  iron, 
and  after  having  taken  it  for  some  time  the  patient  felt  rather  stronger,  but  there  was  no 
improvement  in  the  special  symptoms  of  the  disease. 

Present  State. — February  14th,  i860:  The  patient's  intellect,  memory,  and  speech  are 
quite  normal.  He  does  not  suffer  from  headache,  giddiness,  strabismus,  or  ptosis.  Both 
pupils  are  enlarged,  the  left  more  so  than  the  right.  He  complains  of  weak  sight,  and 
the  ophthalmoscopic  examination  shows  the  arteries  of  the  optic  nerve  smaller  than  usual. 
His  senses  of  hearing,  smell,  and  taste  are  natural.  Respiration  and  heart-sounds  nor- 
mal ;  pulse  at  the  wrist  rather  feeble,  but  quite  regular.  His  digestion  is  tolerably  good. 
Tongue  clean,  appetite  satisfactory,  but  bowels  rather  costive.  He  complains  of  a  sensa- 
tion as  if  a  net  were  tightly  drawn  round  the  abdomen.  He  is  occasionally  troubled  in 
passing  the  urine,  but  there  is  no  stricture.  The  urine  is  of  1030  specific  gravity,  and 
contains  a  sediment  of  urates,  but  no  excess  of  phosphates,  and  no  albumen  or  sugar. 
The  sexual  power  has  not  notably  diminished  of  late.  On  examination  of  the  back  by 
pressure,  percussion,  galvanism,  and  hot  sponges,  no  place  can  be  discovered  which  is 
particularly  sensitive.  The  patient  complains  of  numbness  in  the  hands,  more  especially 
in  the  third  and  fourth  fingers  of  the  left  hand.  He  can  distinguish  heat  and  cold,  and 
feels  the  prick  of  a  pin  and  pressure  distinctly  ;  yet  the  sesthesiometer  shows  a  consider- 
able diminution  of  tactile  sensibility  in  the  fingers.  The  upper  extremities  are  pretty  well 
nourished,  and  the  muscles  answer  well  to  a  galvanic  current  of  moderate  power.  He 
can  bend  and  stretch  the  arms  with  force,  but  he  finds  it  difficult  to  button  his  shirt  and 
to  feed  himself.  The  lower  extremities  are  more  affected  than  the  upper  ones.  The 
patient  has  had  sensations  of  "  pins  and  needles  "  in  the  feet,  but  these  have  for  some 
time  past  given  place  to  numbness.  He  says  that  in  walking  he  has  a  sensation  as  if  the 
steps  rose  under  his  feet.  He  must  continually  look  at  his  limbs  in  order  not  to  lose  his 
balance,  and  can  scarcely  walk  at  all  in  the  dark.  If  told  to  shut  the  eyes  or  stand  with 
both  feet  together,  he  begins  to  stagger.  In  walking  he  throws  the  legs  forwards  with  a 
jerking  motion ;  and,  as  he  cannot  measure  his  distance  from  the  ground,  he  puts  his 
foot  down  with  great  force.  If  lying  down  he  can  bend  and  stretch  the  legs  with  con- 
siderable power ;  but  he  seems  to  exaggerate  every  movement,  all  muscular  contraction 
being,  not  slow  and  equable,  but  violent,  sudden,  and  jerking. 

I  ordered  the  patient  thirty  minims  of  the  syrup  of  iodide  of  iron  three  times  a  day, 
sulphur  baths  twice  a  week,  and  a  pill  of  aloes  and  myrrh  at  bedtime.  After  having  used 
these  remedies  for  about  a  month,  there  was  a  marked  improvement  in  every  respect. 
The  pains  were  nearly  gone,  the  sight  was  rather  better,  the  walking  decidedly  steadier, 
and  less  fatiguing,  and  the  feeling  of  numbness  slighter.  He  went  on  favorably  until 
March,  1861,  when,  having  a  long  and  very  laborious  journey  to  perform,  he  returned  con- 
siderably worse,  and  from  that  time  the  disease  gradually  gained  upon  him  in  spite  of  all 
treatment.  In  1863  he  had  a  course  of  nitrate  of  silver,  but  the  affection  was  then  evi- 
dently too  far  advanced  for  any  medication  to  do  good.     The  sight  got  rapidly  worse, 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.       533 

and  he  became  at  last  completely  amaurotic.  The  sensation  in  the  lower  extremities  was 
also  entirely  lost.  The  patient  was  now  confined  to  his  room,  and  during  the  last  six 
months  of  his  life  he  never  left  his  bed.  His  intellect  remained  unimpaired  to  the  last, 
and  his  disposition  was  always  cheerful.  He  died  in  January,  1865,  of  a  sharp  attack  of 
bronchitis. 

[The  author  then  describes  in  detail  the  anatomical  changes  which  are  found  in  patients 
who  have  succumbed  to  this  disease  ;  after  which  he  proceeds  to  an  elaborate  analysis  of 
the  special  symptoms,  laying  chief  stress  on  the  affection  of  the  cerebral  nerves  and  the 
pains  in  the  first  stage,  and  on  the  symptoms  of  ataxy  and  the  loss  of  the  different  kinds 
of  sensibility  in  the  second  stage  of  the  disorder.  The  causes  generating  ataxy  are  then 
mentioned,  and  the  diagnosis  is  fully  gone  into.     He  then  continues :] 

The  prognosis  is  not  favorable,  for  up  to  the  present  time  not  a  single  case  is  on  record 
in  which  perfect  recovery  has  ensued.  Indeed,  as  late  as  1851,  Romberg  wrote  that 
there  was  no  hope  for  patients  of  this  class,  that  a  fatal  issue  was  inevitable,  and  that  it 
was  but  common  humanity  to  inform  them  that  therapeutic  interference  could  only  injure. 
This  sad  confession  of  impotence  need  no  longer  be  made,  and  we  may  certainly  con- 
gratulate ourselves  on  having  far  more  control  over  the  disease  than  we  had  formerly. 
Moreover,  its  progress  is  seldom  rapid,  although  acute  intercurrent  disorders,  such  as  ery- 
sipelas, bronchitis,  and  pneumonia,  are  grave  complications,  which  may  carry  the  patient 
off  suddenly.  Much  must  depend  upon  the  period  at  which  the  case  comes  under  treat- 
ment. If  all  the  symptoms  of  the  disorder  are  fully  developed,  the  hope  of  a  cure  may 
be  slight,  although  even  then  much  may  be  done  to  alleviate  the  patient's  suffering.  The 
case  is  different  if  the  patient  presents  himself  in  an  early  stage  of  the  disorder.  The  fact 
that  the  cerebral  nerves,  with  the  exception  of  the  optic,  generally  recover  from  their  af- 
fections in  the  course  of  the  disease,  goes  far  to  prove  that  previous  to  the  structural 
changes  in  the  cord  there  is  a  functional  stage,  in  which  much  may  be  done  by  medi- 
cines. Moreover,  we  must  bear  in  mind  that  Messrs.  Charcot  and  Vulpian  have  found 
nervous  fibres  in  the  pi-ocess  of  reparation  in  the  cord  of  a  man  who  had  died  from  ataxy ; 
and  that  therefore  even  at  a  later  time  we  must  not  give  up  hope  altogether,  especially  if 
the  patient  is  placed  in  favorable  circumstances. 

I  now  come  to  the  treatment  of  ataxy,  and  will  first  say  a  few  words  about  diet  and 
regimen.  This  must  depend  a  good  deal  upon  the  condition  in  which  the  patient  is  at 
the  time  he  comes  under  treatment.  If  he  is  in  a  weakly  state,  plain  and  nourishing  diet^ 
with  iron,  quinine,  and  cod-liver  oil,  should  be  prescribed.  I  have  never  seen  a  case  in 
which  lowering  did  any  good.  Hippocrates  has  recommended  milk  diet  in  erotic  tabes, 
and  Eisenmann  speaks  highly  of  the  same  in  progressive  ataxy.  I  have  often  given  milk 
and  brandy,  two  and  even  three  times  a  day,  with  decided  benefit  to  the  general  health, 
but  have  never  found  it  expedient  to  insist  on  an  exclusive  milk  diet.  Exercise  should  be 
very  moderate,  and,  for  those  who  have  undergone  great  fatigue,  rest  is  most  beneficial. 

Counter-irritants  to  the  spine  have  been  used  by  many  physicians,  but,  as  a  rule,  the 
benefit  obtained  has  not  been  proportionate  to  the  sufferings  inflicted  by  their  application. 
The  moxa,  the  hot  ii-on,  issues,  blisters,  and  leeches  have  been  employed.  I  give  the 
preference  over  all  of  these  to  the  continuous  galvanic  current,  applied  to  the  lower  and 
middle  portion  of  the  spine.  It  has  in  several  cases  seemed  to  me  of  decided  benefit  in 
lessening  the  pains,  and  also  the  disagreeable  feeling  of  constriction  which  is  often  felt 
at  the  abdomen  and  the  chest.  The  action  of  this  agent  is  as  rapid  as  that  of  the  iron ; 
its  application  entails  far  less  trouble  and  suffering  than  the  latter ;  and  its  efficacy  is 
superior  to  that  of  issues,  blisters,  and  leeches.  Dry  cupping  on  both  sides  of  the  spine 
is  also  useful. 

Iodide  of  potassium  has  been  recommended  by  Duchenne  and  others;  but  no  cases 


534  PSYCHOLOGICAL    MEDICINE. 

have  been  published  in  which  this  remedy  has  proved  successful.  On  the  contrary,  sev- 
eral are  on  record  in  which  it  seemed  to  accelerate  the  progress  of  the  disease.  I  have 
given  it  in  two  cases,  but  without  any  effect,  and  am  certainly  not  in  favor  of  its  admin- 
istration. Iodide  and  bromide  of  iron  are  useful,  but  do  not  effect  a  cure.  Mineral 
waters  have  been  very  frequently  employed,  both  externally  and  internally  ;  and  it  seems 
that  for  a  time  they  do  good.  Amongst  the  French  spas,  Bareges  is  one  of  the  most 
recommended ;  amongst  the  German  waters,  Marienbad  and  Wiesbaden  have  a  special 
reputation ;  while  chalybeates  and  indifferent  thermal  springs,  which  often  prove  useful 
in  certain  forms  of  paralysis,  have  entirely  failed  in  ataxy.  On  the  whole,  I  should  be 
averse  to  sending  atactic  patients  on  a  journey  to  some  distant  spa,  as  rest  at  home,  with 
certain  remedies  to  be  mentioned  hereafter,  is  more  beneficial  than  all  the  mineral  waters 
in  the  world.  If,  however,  there  should  be  costiveness  and  abdominal  plethora,  Carls- 
bad, Marienbad,  or  Kissingen  water  may  be  drunk  at  home  with  benefit.  Sulphur  baths 
may  also  be  taken  at  home,  and  I  think  highly  of  them.  I  have  never  employed  them 
alone ;  but  they  certainly  seemed,  in  conjunction  with  other  remedies,  to  do  much  in  re- 
lieving the  pains  and  diminishing  the  numbness.  The  patients  feel  more  brisk  and  supple 
after  the  baths,  and  are  almost  always  desirous  of  repeating  them  as  often  as  possible. 
A  sulphur  bath  may  be  prepared  by  dissolving  from  three  to  six  ounces  of  the  sulphuret 
of  potassium  in  two  pints  of  warm  water,  and  adding  this  to  the  bath.  Vapor  baths  and 
Turkish  baths  should  be  avoided. 

Nux  vomica  and  strychnine  have  frequently  been  used,  but  generally  seemed  to  do 
harm.  Duchenne  recommends  faradization,  and  the  late  Professor  Remak,  of  Berlin, 
praised  galvanization  as  a  curative  agent.  From  faradization  I  have  never  seen  any 
benefit;  galvanization  has  proved  useful  at  my  hands,  not  only  in  the  pain  and  feeling  of 
constriction,  but  also  in  the  affections  of  cerebral  nerves,  which  are  so  frequent  in  the 
commencement  of  ataxy ;  on  the  other  hand,  it  has  been  powerless  against  the  disease 
itself,  more  especially  against  the  symptom  of  ataxy. 

Amongst  the  other  remedies  which  have  been  used  in  this  affection  without  much  re- 
sult I  will  mention  opium,  bromide  of  potassium,  secale  cornutum,  essence  of  turpentine, 
and  arsenic.  The  only  remedy  which  seems  as  yet  to  have  done  some  good,  in  a  very  large 
proportion  of  cases,  is  the  nitrate  of  silver,  given  in  doses  of  one-tenth  to  a  half  grain  two 
or  three  times  a  day.  Professor  Wunderlich,  of  Leipzic,  was  the  first  who  employed 
silver  in  seven  cases  of  this  disease,  in  none  of  which,  it  is  true,  he  obtained  an  actual 
cure,  but  in  most  of  them  considerable  improvement.  In  1862,  Messrs.  Charcot  and 
Vulpian,  in  France,  took  up  Wunderlich's  idea,  and  used  the  nitrate  in  five  other  cases, 
and  in  each  of  them  there  was  much  amendment.  Since  then  this  remedy  has  been  em- 
ployed in  most  cases  of  ataxy,  and  with  somewhat  variable  success.  In  some  it  has  so 
disagreed  with  the  patients  that  it  was  necessary  to  discontiuue  its  use ;  in  others  it  had 
little  or  no  effect;  while  in  the  majority  of  cases  the  remedy  has  proved,  if  not  curative, 
at  least  very  useful,  and  it  is  the  one  upon  which  most  reliance  can  be  placed  in  the  treat- 
ment of  this  disease.  I  am  in  the  habit  of  giving  the  silver  combined  with  the  hypo- 
phosphite  of  soda,  and  it  seems  to  do  far  more  in  this  combination  than  either  of  these 
remedies  singly.  I  have,  indeed,  now  a  case  of  ataxy  under  my  care  in  which  the  im- 
provement has,  for  the  last  six  months,  been  so  considerable  under  this  medication  that  I 
am  hopeful  of  a  cure.  Certain  precautions  should,  however,  be  taken  in  administering 
the  nitrate.  I  generally  employ  it  for  four  or  six  weeks  consecutively,  and  then  discon- 
tinue it  for  a  fortnight  or  three  weeks,  giving  in  the  meantime  a  slightly  aperient  mineral 
water.  After  this  the  use  of  the  remedy  may  be  safely  recommenced,  and  continued  for 
a  month  or  so.  The  gums  must  be  inspected  from  time  to  time,  as  the  peculiar  colora- 
tion which  silver  produces  in  the  long  run  fiist  appears  in  the  mucous  membrane,  and 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.       535 

only  afterwards  in  the  skin.  With  the  precautions  mentioned,  however,  no  disfigurement 
of  the  patient  need  be  feared.  I  have  never  gone  beyond  the  dose  of  half  a  grain,  and 
perhaps  this  is  another  reason  why  in  my  cases  the  remedy  has  been  borne  without 
any  inconvenience.  I  should,  however,  not  recommend  all  cases  of  ataxy  to  be  treated 
alike;  in  this  affection  we  must,  as  in  every  other,  study  each  individual  case  by  itself, 
and  advise  for  it  v^'hat  seems,  under  the  special  circumstances,  most  likely  to  do  good. 
Thus  hysterical  or  hypochondriacal  patients  in  whom  ataxy  may  supervene  will  require  a 
different  treatment  from  plethoric  persons,  or  such  as  have  long  suffered  from  rheumatism, 
or  have  been  subject  to  privations  and  anxiety.  Much  is,  therefore,  left  to  the  tact  and 
discrimination  which,  together  with  knowledge,  should  in  all  cases  brought  before  him, 
guide  the  doings  of  the  physician. 

Dr.  Johnson,  at  King's  College  Hospital,  says : 

[The  disease  known  as  locomotor  ataxy  has  been  much  discussed  within  the  last  few 
years  by  Duchenne  and  others,  under  the  name  of  "  ataxic  locomotrice."  This  disease 
had  until  recently  been  included  in  the  class  Paraplegia ;  but  in  well-marked  cases  there 
is  no  actual  paralysis  of  the  muscles,  but  loss  of  power  to  guide  them.  The  patient  is 
obliged  to  "  lean  on  his  eyesight  as  on  crutches;"  and  if  he  shuts  his  eyes  he  stops,  and 
sometimes  falls.  The  posterior  column  of  the  cord  is  the  part  diseased.  The  following 
is  the  account  of  a  case  in  a  man  forty  years  of  age.  He  had  from  boyhood  been  engaged 
in  the  cod-fishery  off  Iceland,  and  thus  for  the  greater  part  of  the  year  was  much  exposed 
to  wet  and  cold.     The  symptoms  of  the  disease  dated  four  years  back.] 

On.  admission,  he  was  noted  as  a  short,  well-built,  powerful  man;  no  loss  nor  thick- 
ening of  speech,  and  no  deafness.  He  seemed  to  be  intelligent,  and  gave  a  clear  account 
of  himself.  The  most  characteristic  point  was  his  walk.  He  could  stand  very  well  with 
his  feet  apart,  but  when  he  put  them  close  together  he  could  not  maintain  his  position, 
even  when  looking  on  the  ground.  On  taking  a  step,  he  would  advance  in  a  hesitating, 
tottering  manner.  He  always  leaned  forwards,  and  seemed  to  have  some  difficulty  in 
balancing  himself,  especially  when  turning  round.  These  points  were  better  seen  when 
he  shut  his  eyes,  for  he  was  only  able  to  totter  a  few  yards,  and  then  would  fall.  He 
walked  pretty  well  when  his  eyes  were  off  the  ground,  as  when  he  was  looking  at  the 
ceiling;  but  directly  he  closed  his  eyes  he  seemed  to  lose  all  confidence,  and  reeled  like 
a  drunken  man.  Although  there  was  this  loss  of  power  in  coordinating  his  movements, 
there  was  no  loss  of  muscular  power.  He  would  lift  heavy  weights,  and  even  carry 
patients  round  the  ward.  When  sitting  in  a  chair  with  bent  knees,  he  could  resist  all 
attempts  to  straighten  the  legs.  There  was  no  muscular  atrophy,  and  but  slightly  dimin- 
ished sensation  in  the  left  hand.  The  left  side  was  rather  more  affected  than  the  right. 
It  appears  he  had  a  chancre  four  years  ago,  but  it  came  on  after  the  first  appearance  of 
numbness  in  the  leg.  There  were  some  syphilitic  patches  on  the  tongue.  There  was  no 
sore-throat  nor  rash  on  the  skin;  no  nodes,  nor  glandular  swellings  anywhere.  Lung 
and  heart-sounds  healthy.  Urine  pale;  specific  gravity  loio;  no  albumen.  Does  not 
pass  urine  more  than  three  or  four  times  a  day.  His  intellectual  faculties  do  not  seem 
impaired;  he  has  slight  loss  of  memory.  His  sight  is  not  quite  so  good  as  it  was.  He 
has  no  pains  in  his  head  nor  down  the  spine.  Hearing  and  speech  good.  No  affection 
of  the  cranial  nerves  apparently.  Appetite  good.  Bowels  open;  no  loss  of  power  over 
the  sphincters. 

He  was  put  on  a  liberal  diet,  and  treated  with  iron  and  quinine.  Galvanism  was 
applied  daily,  with  apparent  benefit. 

During  his  stay  in  the  hospital  he  seemed  to  improve  a  little.     At  times  he  would  walk 


536  PSYCHOLOGICAL   MEDICINE. 

fairly  well,  but  on  wet  days  he  was  always  worse,  and  depression  of  spirits  would  come 
on.     He  was  discharged  Feb.  Sth,  1866. 

In  a  case  of  progressive  locomotor  ataxy,  under  the  care  of  Dr. 
Hughlings  Jackson,  at  the  London  Hospital,  he  observed  that  this 
was  one  of  the  most  interesting  cases  of  locomotor  ataxy  that  he  had 
ever  seen : 

The  patient  was  39  years  of  age.  The  first  symptoms  obsei'ved,  when  14  years  of  age, 
was  I'jss  of  sight;  but  this  improved  so  that  in  nine  weeks  he  was  able  to  see  tolerably. 
He  then  became  almost  quite  deaf,  and  then  the  senseof  smell  was  lost.  Taste  has  never 
been  affected.  There  was  also  clear  evidence  of  diminished  sensation  in  the  legs.  The 
patient  is  liable  to  sudden  and  violent  pains  in  the  legs. 

The  patient  can  get  along  when  his  eyes  are  open ;  but  his  gait  is  precipitate,  and  he 
staggers.  \Yhen  he  shuts  his  comparatively  good  eye,  he  can  only  manage  to  keep  his 
legs  for  a  moment.  It  is  scarcely  right  to  say  that  he  can  stand;  a  fairer  description 
would  be,  he  does  not  fall  at  once.  He  cannot  stir  a  step  with  his  eyes  shut.  Dr. 
Jackson  particularly  drew  our  attention  to  the  fact  that  this  patient  could  manage  to  walk 
when  looking  at  the  ceiling,  although,  of  course,  not  so  well  in  so  awkward  a  position. 
He  (Dr.  Jackson)  told  us  that  a  year  ago  he  had  had  under  his  care  a  man  suffering  from 
locomotor  ataxy  who  could  walk  whether  he  looked  on  one  side  or  at  the  ceiling.  And 
he  remarked  that,  although  most  patients  suffering  from  ataxy  say  they  "  must  look  at 
their  feet,"- some  can  walk  without  doing  so  if  their  eyes  are  open.  The  last-mentioned 
patient  could  walk  with  his  eyes  shut  if  he  merely  touched  a  wall  with  his  fingers  without 
resting  any  of  his  weight  on  it.  Another  patient,  who  was  quite  blind,  and  whom  we 
saw  with  Dr.  Jackson  at  the  Hospital  for  Epilepsy  and  Paralysis,  averred  that  he  could 
walk  for  a  long  distance  in  the  park  if  he  just  touched  the  railing  with  one  hand ;  and, 
on  trial,  it  was  found  that  he  could  get  along  much  better  than  we  could  have  expected 
in  this  way.  More  than  one  patient  has  said  that,  when  they  shut  their  eyes,  they  "  feel 
as  if  there  was  nothing  under  them."  It  seems  only  necessary  in  these  cases.  Dr.  Johnson 
said,  for  the  patients  to  establish  some  definite  relation  with  the  objects  about  them.  The 
patient's  wife  said  that  he  began  to  stumble  about  a  year  after  the  blindness.  He  had 
first  pain  in  his  back,  and  there  were  some  lumps  on  it;  but  no  precise  information  could 
be  obtained  on  these  points. 

The  patient  has  had  difficulty  with  his  bladder  eleven  years,  and  this  may  possibly  be 
essentially  a  motor  defect.  If  so,  it  is  the  only  paralysis.  The  patient  can  stamp  well 
with  his  legs,  can  resist  flexion  and  extension  fairly,  and  his  legs  are  well  nourished. 
There  is  no  paralysis  of  any  one  of  the  cranial  motor  nerves,  nor  any  history  of  squinting. 

The  man  seems  intelligent.  His  talk  is  rather  odd,  but  there  is  none  of  the  thickness 
of  general  paresis  about  it.  He  talks  in  the  loud  harsh  way  some  people,  who  have  long 
been  very  deaf,  get  into.  He  was  so  deaf  that  it  required  much  patience  to  obtain  a  few 
facts  from  him.  Dr.  Jackson  at  first  tried  to  communicate  with  him  by  writing  words  of 
monstrous  size  on  paper.  In  this  way  he  got  to  know  that  the  patient  denied  sexual 
excesses,  and  that  he  used  to  drink  hard,  and  also,  a  fact  that  is  worth  notice,  that  he  had 
smoked  an  ounce  of  tobacco  a  day  for  eighteen  years. 


LOCOMOTOR   ATAXIA — CEREBRAL    HYPEREMIA,    ETC.  53/ 


GENERAL  OBSERVATIONS  ON  ABNORMAL  STATES  OF  THE  BRAIN; 
CONGESTION,  SOFTENING,  AND  SCLEROSIS. 

I.  Cerebral  Hyper(Einia  or  Congestion. — This  state  consists  in  an 
increase  in  the  quantity  of  blood  contained  in  the  capillaries  of  the 
brain.  It  may  be  active  or  passive  ;  the  former,  when  the  capillaries 
are  filled  with  rapidly  moving  arterial,  oxygenated  blood;  the  latter, 
when  from  venous  obstruction  the  capillaries  contain  slowly  moving 
blood  of  a  venous  character.  A  man  who  is  plethoric,  or  a  child 
with  a  sensitive  vaso-motor  system,  may  have  active  cerebral  hy- 
peraemia,  owing  to  increase  of  blood-pressure;  or  the  man  may  have 
an  active  arterial  dilatation  of  vaso-motor  origin  from  prolonged 
mental  work,  severe  moral  emotion,  sunstroke,  gastro-hepatic  dis- 
turbance, or  from  toxic  poisoning,  as  by  alcohol,  etc.,  or  an  increased 
atmospheric  pressure,  or  lying  with  the  head  too  low.  We  may  get 
a  partial  active  cerebral  congestion  from  disease  of  cerebral  blood- 
vessels or  organic  disease  of  the  brain. 

Passive  cerebral  hyperaemia  generally  is  the  result  of  impeded 
return  of  blood  from  the  head,  due  either  to  mechanical  pressure  on 
the  veins,  to  tricuspid  insufficiency  with  the  associated  condition  of 
the  lungs,  or  a  diseased  heart.  Cerebral  thrombosis  in  a  vein,  or  a 
morbid  growth  or  tumor  exercising  pressure  on  a  cerebral  sinus, 
may  also  be  the  cause  of  passive  congestion. 

Clinically,  when  we  are  called  upon  to  see  a  case  of  cerebral 
hyperaemia,  we  shall  find  a  good  deal  of  mental  irritability  in  our 
patient.  Slight  causes  may  cause  quite  an  explosion  of  anger.  If 
we  evert  the  lower  eyelid,  we  shall  find  dilated  and  tortuous  blood- 
vessels, which  indicate  very  well  the  condition  of  the  cerebral  circu- 
lation. The  conjunctiva  may  be  suffused,  and  the  patient  will  com- 
plain of  headache,  which  may  be  slight  or  intense,  and  of  flashes  of 
light  before  the  eyes,  noises  in  the  ears,  and  there  may  be  nausea. 
There  may  be  also  confusion  of  mind  and  sleeplessness.  The  patient 
complains  of  a  feehng  of  fulness  or  of  throbbing  in  the  head,  and  the 
head  is  hot,  and  the  face  of  a  deep-red  color  perhaps.  The  pulse  is 
rapid  and  irritable,  or  slow  and  labored,  and  the  pupils  contracted, 
and  the  sight  dim  and  defective.  Motor  power  is  lessened,  so  that 
the  patient  feels  unequal  to  even  slight  exertions.  Patients  are  unani- 
mous in  giving  a  history  of  a  heavy,  unrefreshing  sleep,  if  they  do 
sleep,  and  of  feeling  much  worse  in  the  morning,  and  they  complain 
of  numbness  in  the  extremities.     Patients  who  pursue  their  ordinary 


538  PSYCHOLOGICAL   MEDICINE. 

avocations  do  their  work  mechanically,  and  feel  as  if  they  were  semi- 
conscious, and  pay,  perhaps,  very  little  attention  to  what  you  say, 
owing  to  the  overwrought  condition  of  their  nervous  system.  This 
state  may  last,  if  not  relieved,  for  days,  weeks,  or  months,  and  there 
is  a  convulsive  form  in  which  there  are  slight  muscular  spasms,  with 
or  without  loss  of  consciousness.  A  maniacal  delirium  may  develop, 
as  the  result  of  a  subinflammatory  irritation  of  the  brain,  set  up  by 
the  hyperaemic  state  of  that  organ,  although  there  is  a  distinct  de- 
lirium of  congestion  of  the  brain  found  only  in  advanced  years.  If 
cerebral  hyperaemia  is  not  relieved,  there  is  danger  of  apoplectiform 
attacks,  in  which  Russell  Reynolds  and  Bastian  have  shown  that 
sensation,  consciousness,  and  power  of  motion  are  lost.  The  patient's 
senses  are  temporarily  in  abeyance,  and  the  pulse  and  respiration  are 
disturbed  for  a  few  moments.  These  symptoms  pass  off  in  a  half- 
hour,  but  if  they  recur  are  more  prolonged,  both  in  duration  and 
intensity.  In  the  preliminary  or  premonitory  stage  the  patient,  be- 
sides motor  weakness  and  irritability,  may  complain  of  pains  simu- 
lating the  pain  of  locomotor  ataxia.  They  differ  in  not  being  so 
severe,  but  they  sometimes  are  very  annoying,  and  I  have  known 
physicians  to  be  much  disturbed  by  them.  They  often,  I  think, 
accompany  neurasthenia,  with  an  overwrought  state  of  the  nervous 
system,  and  are  merely  dependent  upon  the  hyperaesthetic  state  of 
the  whole  cerebro-spinal  system,  as  they  entirely  disappear  as  the 
patient  recovers.  The  symptoms  of  cerebral  congestion  from  the 
presence  of  alcohol  are  often  very  severe.  The  delirium  may  be 
very  violent,  the  patient  very  aggressive,  with  no  conception  of  his 
condition  or  surroundings,  and  there  are  often  delusions  relating  to 
place,  the  patient  fancying  himself  in  some  other  locality.  The  face 
is  of  a  dusky  red  color,  and  the  pulse  generally  very  quick,  and 
vomiting  is  often  present.  It  has  so  happened  that  the  majority  of 
cases  that  we  have  personally  come  in  contact  with  have  been  those 
of  active  arterial  dilatation  of  vaso-motor  origin,  in  business  and 
professional  men,  due  to  overwork  and  overstrain  of  the  brain,  with 
symptoms  of  premature  mental  decay.  There  has  been  in  all  these 
cases  an  overwrought  state  of  the  nervous  system,  owing  to  excessive 
care,  worry,  or  mental  anxiety,  combined  with  overwork.  Dr.  Rus- 
sell Reynolds  and  Dr.  Bastian  speak  of  the  final  symptoms  as  being 
a  condition  of  torpor  and  inactivity:  "The  mind  becomes  a  blank. 
There  is  profound  coma,  stertorous  breathing,  and  involuntary  evacu- 
ations of  both  bladder  and  rectum.     Sensibility,  both  general  and 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.       539 

special,  is  lost,  and  voluntary  muscular  power  reduced  to  a  minimum. 
Convulsions  may  occasionally  disturb  the  calm,  or  there  may  be  fitful 
and  momentary  mutterings  of  unintelligible  sounds;  but  usually  in 
this  latter  stage  the  patient  lies  quietly,  with  labored  pulse  and 
breathing,  and  with  flickering  contractions  of  the  muscles  of  the 
limbs  until  he  dies." 

Treatinejit. — Of  course,  the  indications  for  treatment  are  to  control 
the  amount  of  blood  existing  within  the  cranium,  by  bringing  to  bear 
antagonistic  agents  to  the  congestive  state.  Of  course,  we  must 
order  prompt  cessation  of  the  prolonged  study  and  over  mental  work 
of  professional  men,  and  rest,  both  for  them  and  the  overworked 
business  man. 

We  must  also,  in  cases  where  the  congestion  is  due  to  mechanical 
impediments  to  the  proper  return  of  blood  from  the  brain,  do  all  in 
our  power  to  keep  the  heart  and  lungs  working  normally.  We  must 
warn  our  patient  to  avoid  great  elevations  and  alternations  of  tem- 
perature, exposure  to  the  sun's  rays,  alcohol,  and  sleeping  with  the 
head  too  low.  Dry  cupping  at  the  back  of  the  neck,  placing  the  feet 
and  hands  in  hot  mustard  water,  an  ice-cap  to  the  head,  ice  held 
directly  on  the  nape  of  the  neck,  the  induction  of  free  diuresis,  un- 
loading a  packed  colon,  the  administration  of  the  fluid  extract  of 
ergot  in  Jss  to  3j  doses  ter  die,  in  combination  with  the  bromide  of 
sodium,  Fothergill's  solution  of  hydrobromic  acid,  and  last,  but  not 
least,  the  use  of  cerebral  electrization,  as  described  in  the  chapter  on 
electricity,  are  all  to  be  used/r*?  re  nata. 

The  cautious  use  of  stimulants  is  indicated  when  there  is  a  feeble 
pulse  and  pale  surfaces,  as  sometimes  happens  in  asthenic  cases. 
Many  cases  need  a  tonic  after  the  first  symptoms  have  been  con- 
trolled, and  there  is  none  better  in  the  case  of  overworked  profes- 
sional and  business  men  than  "  Warburg's  tincture  "  in  5j  doses  be- 
fore breakfast  daily.  It  is  disagreeable,  but  should  be  taken  clear 
on  an  empty  stomach.  It  may  be  taken  in  divided  doses  in  capsules, 
to  obviate  the  disagreeable  taste.  The  elixir  of  the  phosphate  of 
iron,  quinine,  and  strychnia  is  also  good,  or  the  liquor  acid.  phos. 
comp.  with  five-minim  doses  of  the  tincture  of  nux  vomica  before 
each  meal,  the  acid  to  be  taken  after  meals.  The  advantage  of  static 
electricity  as  a  nerve  sedative  I  believe  to  be  very  great,  and  general 
faradization  as  an  excellent  tonic  and  refreshant  to  the  system.  Per- 
sons living  by  the  sea  should  seek  mountain  air,  avoiding  too  high 
altitudes,  while  those  living  inland  and  in  the  south  will  be  bene- 


540  PSYCHOLOGICAL   MEDICINE. 

fited  by  a  residence  by  the  seaside  during  the  summer  months.  Rest 
for  body  and  mind  is  imperative. 

2.  Cei^ebral  Softening — Brain-softening  should  be  a  symptom  of 
senihty,  associated  with  a  general  enfeebled  condition  and  impaired 
nutritive  power.  The  general  failure  of  cerebral  power  is  often  thus 
found  in  the  aged,  with  rigid  arteries  and  arais  senilis.  It  is,  how- 
ever, we  believe,  becoming,  owing  to  the  complex  influences  of  our 
modern  civilization,  a  much  more  frequent  occurrence  in  business 
and  professional  men  than  formerly.  There  is  a  premature  mental 
decay,  the  result  of  the  combined  effect  of  overwork,  mental  anxiety, 
and  loss  of  rest  (the  brain-cells  missing  the  proper  time  for  their 
nutritive  renovation,  which  is  during  sleep),  which  is  pre-eminently 
an  American  disease,  the  premonitory  signs  of  which  I  have  seen  in 
many  comparatively  young  men. 

Softening  of  the  brain  is  aptly  defined  by  Reynolds  and  Bastian 
as  a  disease  characterized  during  life  by  impairment  of  mind,  sensi- 
bility, and  motility,  and  after  death  by  diminished  consistence  and 
degeneration  of  the  cerebral  substance.  I  think  that  sometimes  an 
erroneous  diagnosis  is  made  by  confounding  with  cerebral  softening, 
the  state  of  brain-wasting  accompanied  by  cerebral  atrophy  and 
hardening  of  brain-tissue.  The  seat  of  the  morbid  change  is  more 
frequently  the  cortex  of  the  brain,  the  corpus  striatum,  and  the  optic 
thalamus.  It  has  also  been  found  in  the  pons,  medulla,  and  in  the 
cerebellum,  and  may  be  found  anywhere  in  the  brain.  There  is 
diminished  consistence  of  the  brain-tissue  wherever  we  meet  with 
this  lesion.  If  the  softening  be  due  to  embolism,  we  shall  very 
likely  find  no  symptoms  but  heart  lesions,  with  the  exception  of 
momentary  attacks  of  faintness.  If  the  softening  is  due  to  arterial 
disease,  Gowers  has  shown  that  we  get  mental  deterioration,  numb- 
ness, pains  in  the  limbs,  or  slight  local  weakness.  We  may  have 
hemiplegia  and  aphasia  occurring  in  embolism,  with  mental  deteri- 
oration. There  may  be  apoplectic  attacks,  with  slight  loss  of  con- 
sciousness and  the  quick  disappearance  of  the  apoplectic  symptoms, 
or  there  may  be  convulsive  or  delirious  symptoms  at  the  onset  of 
cerebral  softening. 

There  is  a  class  of  cases,  illustrated  by  the  one  we  are  about  to 

give,  not  uncommon.     Mr. ,  aged  38,  had  had  domestic  trouble 

and  grief;  had  been  addicted  to  rather  free  use  of  alcohol,  and  gave 
a  history  of  what  we  presume  was  acute  cerebral  congestion,  the  re- 
sult of  the  combined  effect  of  mental  worry  and  alcohol,  but  which 


LOCOMOTOR   ATAXIA — CEREBRAL    HYPERiEMIA,   ETC.  54I 

he  designated  as  "  brain  fever."  Upon  coming  under  our  care  we 
carefully  examined  him,  and  found  mental  dulness,  loss  of  memory, 
especially  for  recent  events,  the  emotional  nature  very  easily  excited, 
the  motor  power  much  weakened,  great  disinclination  for  mental  or 
physical  effort,  headache,  articulation  at  times  rather  indistinct. 
Sight  and  hearing  were  good,  there  were  no  symptoms  of  paralysis 
and  the  reflexes  were  normal.  Just  previous  to  my  seeing  him,  a 
small  quantity  of  alcohol  had  produced  a  transient  delirium,  of  which 
my  patient  had  no  recollection  at  all.  He  said,  when  I  questioned 
him,  that  he  was  angry  because  one  of  his  relatives  had  counter- 
manded his  order  for  some  whiskey,  but  had  no  recollection  of  having 
drank  the  liquor  and  the  state  of  delirium  it  had  induced.  Respect- 
ing all  this  his  mind  was  a  perfect  blank.  He  would  read  a  newspaper 
for  an  hour  and  be  utterly  unable  to  tell  in  two  hours  what  he  had 
been  reading.  Although  there  was  this  profound  affection,  there 
was  great  mental  improvement  under  the  influence  of  electrization, 
the  chloro-phosphide  of  arsenic  (Routh's  formula),  iron,  and  strych- 
nia, and  cod-liver  oil.  So  much  so  that  we  discharged  the  patient, 
and  he  has  passed  the  last  six  months  in  the  country,  living  much  out 
of  doors  and  enjoying  life  very  well. 

I  do  not  consider  that  in  his  case  or  any  other,  that  damaged  brain- 
tissue  can  ever  regain  its  lost  functional  power,  but  we  may  check 
the  progress  of  the  disease,  in  some  cases,  by  strict  hygienic  regula- 
tions for  our  patient,  and  by  rest,  together  with  a  similar  course  of 
treatment  to  that  I  have  described. 

The  premonitory  symptoms  of  the  apoplectic  form  of  cerebral  soft- 
ening are,  according  to  Russell  Reynolds  and  Bastian,  those  of  tran- 
sient excitement,  talkativeness,  irritability,  or  wandering  of  thought, 
amounting  to  mild  delirium  lasting  for  a  few  minutes.  He  may  then 
fall  to  the  ground  and  remain  partially  or  wholly  insensible  for  a  few 
moments,  owing  either  to  cerebral  congestion  or  anaemia.  Subse- 
quently to  this  he  may  be  hemiplegic  and,  aphasic,  or  chronic  soften- 
ing may  go  on,  the  patient  becoming  imbecile  and  powerless. 

The  premonitory  symptoms  of  the  convulsive  form  and  of  the 
delirious  form  are  stated  by  the  same  authorities  to  be  in  the  former, 
a  peculiar  drowsiness,  listlessness,  weariness,  impatience,  or  some 
flaw  in  memory,  with  distinct  but  momentary  incapacity  to  under- 
stand what  is  said.  There  may  be  a  slight  hesitancy  in  speech,  mis- 
pronunciation of  a  few  words,  a  little  weakness  of  one  side,  numb- 
ness, vertigo  or  faintness,  until  the  convulsion  occurs  resembling  an 


542  PSYCHOLOGICAL   MEDICINE, 

epileptic  convulsion  and  makes  the  grave  nature  of  the  case  clear. 
The  patient  lies  in  a  semi-comatose  state  and  has  a  succession  of  fits, 
which  may  leave  the  patient  hemiplegic.  The  prognosis  in  these 
cases  is  very  grave.  In  the  latter,  the  delirious  form,  which  gene- 
rally occurs  in  the  aged,  "  the  patient  suddenly  '  wanders '  in  his  talk, 
becomes  loquacious  or  restless,  is  busy  in  manner,  exerts  himself, 
seems  tired,  and  falls  asleep.  He  wakes  up  somewhat  confused,  but 
appears  to  be  himself  again  for  a  few  days  or  even  weeks,  when  the 
confusion  and  delirium  reappear,  and  are  more  persistent.  There  is 
no  complete  restoration,  but  gradually  one  side  is  found  to  be  para- 
lyzed, or  to  be  slightly  weaker  than  the  other.  The  delirium  alter- 
nates with  coma,  more  or  less  profound,  and  the  patient  passes  into  a 
state  like  that  following  the  apoplectic  form."  The  final  symptoms 
of  brain  softening  are  those  of  coma  and  death,  quiet  and  painless. 
Precocious  children  are  said  by  Duparque  to  develop  brain  soften- 
ing with  the  intellect  intact,  and  with  exaltation  of  the  special  senses 
and  general  sensibility.  There  is  no  fever,  delirium,  or  convulsion, 
but  after  death  there  is  distinct  cerebral  ramollissement. 

Brain-softening  in  comparatively  young  men  I  should  consider  as 
owing  to  a  premature  failure  of  the  proper  activity  of  the  cellular  ele- 
ments of  the  brain  tissue,  with  very  likely  disease  of  the  coats  of  the 
capillaries  and  small  arteries,  commencing  with  cerebral  hypersemia 
and  subinflammatory  irritation. 

The  cerebral  softening  of  the  aged  is  due  generally  to  vascular 
obstruction  in  the  brain,  either  arterial  or  capillary.  Thrombosis, 
with  vascular  degeneration,  and  embolism,  with  valvular  disease  of 
the  heart,  are  doubtless  the  most  frequent  causes  of  softening  of  the 
brain. 

Disseminated  Sclerosis  of  the  Brain  and  Spinal  Cord. — Syn.  "  Scle- 
rose en  plaques  disseminees  "  (Charcot). — To  Professor  Charcot  be- 
longs the  credit  of  first  recognizing  this  disease,  which  consists  in 
the  development  of  patches  of  sclerosis  of  a  roundish  shape,  and 
dense  and  hard,  gray  in  color,  looking  like  the  gray  matter  of  the 
brain.  These  patches,  which  are  of  varying  size  and  shape,  are 
scattered  throughout  the  brain,  or  the  brain  and  cord,  in  different 
localities,  and  more  often  in  the  brain  and  cord  together.  These 
patches  vary  in  size,  according  to  Bastian,  from  that  of  a  pin's  head 
to  that  of  a  large  pea  or  bean  in  the  spinal  cord,  while  in  the  brain 
or  cerebellum  they  may  be  still  larger.  The  medulla,  pons,  and 
cerebral  peduncles  may  be  affected,  and  any  part  of  the  cerebrum 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPER^.MIA,  ETC.      543 

and  cerebellum.  Microscopically,  there  is  a  hyperplastic  overgrowth 
of  the  neuroglia,  which  exists  normally  around  and  between  the 
nerve-elements.  In  employing  carmine  staining,  the  new  growth 
takes  up  the  coloring-matter  very  intensely.  When  the  lateral 
columns  of  the  cord,  the  medulla,  and  the  pons  are  affected,  which 
are  special  seats  of  election  for  these  patches  of  sclerosis,  Bastian 
gives  the  following  as  the  clinical  symptoms:  A  slowly  ensuing 
paresis  of  the  lower  extremities  begins,  first  in  one  limb,  and  then, 
after  a  time,  it  involves  the  other.  During  this  time  the  paresis 
develops  into  a  more  and  more  marked  paralysis,  though  the  sensi- 
bility of  the  limbs  remains  almost  completely  unaffected,  nothing 
more  than  a  temporary  numbness  being  complained  of  in  the  ma- 
jority of  cases,  whilst  lightning-like  pains  and  girdle  sensations  are 
altogether  absent.  After  an  interval,  first  one  and  then  another 
upper  extremity  may  become  weak,  and  subsequently  more  or  less 
paralyzed.  During  these  early  stages  of  the  disease,  more  or  less 
distinct  remissions  of  symptoms  may  occur  from  time  to  time. 
Meanwhile,  a  most  typical  sign  soon  shows  itself  in  the  paretic  or 
semi-paralyzed  limbs,  in  the  form  of  a  marked  trembling  or  shaking 
of  those  muscles  or  parts  of  a  limb  which  are  called  into  voluntary 
action  with  any  intensity,  although  these  phenomena  immediately 
subside  when  the  voluntary  exertion  ceases.  The  involuntary  move- 
ments consist  either  of  extremely  well-marked  tremors,  like  those 
met  with  in  some  cases  of  paralysis  agitans,  or  else  of  movements 
of  greater  range,  more  resembling  those  of  chorea.  A  patient  lying 
in  bed  quietly,  when  told  to  sit  up,  will  exhibit  shakings  and  tremors 
in  all  parts  of  the  body  until  he  lies  down  again.  In  writing,  almost 
every  letter  registers  fine  tremors,  and  in  the  advanced  cases  writing 
is  impossible  or  illegible.  The  tendon  reflexes  are  exaggerated,  both 
the  patellar  tendon  and  the  ankle  clonus  Contractions  and  rigidity 
come  on  late  in  the  course  of  the  disease.  The  tremors,  which  are 
rhythmical,  of  the  head,  neck,  trunk,  and  limbs,  cease  when  the  patient 
is  asleep,  as  well  as  when  he  lies  quietly  at  rest.  There  is  a  difificulty 
of  speech,  the  utterance  being  slow  and  drawling,  while  the  lips  and 
tongue  are  tremulous.  There  is  apt  to  be  double  vision,  also  indis- 
tinct, hazy  vision,  and  nystagmus  (oscillations  of  the  eyeballs)  is 
frequently  present.  Vertigo  of  a  gyratory  nature,  frequently  im- 
peding locomotion,  exists  as  an  early  symptom.  Mental  failure  in 
cases  where  the  brain  is  affected  is  a  late  symptom,  accompanied  at 
times,  according  to  Bastian,  by  a  subacute  maniacal  condition,  or  by 


544  PSYCHOLOGICAL   MEDICINE. 

delusions  of  wealth  and  grandeur,  like  those  of  paralytic  dementia, 
or  by  a  profound  melancholia.  Apoplectiform  or  epileptiform  attacks 
may  now  occur  from  time  to  time,  and  death  may  take  place  in  one 
of  them.  The  course  of  the  disease  may  be  from  five  to  ten  years. 
When  the  disease  affects  the  brain  particularly  and  principally, 
vertigo,  mental  disturbance,  nystagmus,  and  the  "scanning"  speech 
will  be  the  chief  symptoms,  beside  the  rhythmical  tremors.  Paresis 
of  the  limbs,  commencing,  as  we  have  said,  in  one  leg,  is  an  early 
symptom. 

A  case  recently  came  under  our  notice  of  a  gentleman  of  forty-two 
years,  plethoric,  a  high  liver,  with  a  fair  family  history,  who  devel- 
oped this  disease,  and  who  died  in  about  three  years  from  the  time 
the  first  symptoms  manifested  themselves.  Vertigo  was  the  earliest 
symptom  he  complained  of,  and  it  was  this  that  first  led  him  to  apply 
to  a  physician  for  relief,  as  he  would  fall  down  from  the  gyratory 
nature  of  it.  The  small  oscillation  of  the  eyeballs  (nystagmus) 
was  very  marked.  Paresis  terminated  in  complete  motor  paralysis. 
Speech  was  affected.  Sensibility  was  normal.  Trembling  on  vol- 
untary^ movement  was  most  marked.  Xo  treatment  had  any  effect. 
Electricity,  strj'chnia,  and  various  combinations  were  all  tried,  and 
all  failed.  The  case  was  under  the  care  of  one  of  our  best  neurolo- 
gists. 

Locomotor  ataxia,  terminating  as  general  paralysis  of  the  insane, 
was  reported  by  Charles  K.  Mills,  M.D.,  of  Philadelphia,  before  the 
American  Neurological  Association,  June  20,  1883.  Dr.  Mills  said 
that  the  relation  between  locomotor  ataxia  and  general  paralysis  of 
the  insane  has  been  a  problem  of  interest  to  neurologists  and  alienists 
since  the  investigations  of  Westphal,  in  1863. 

He  related  the  following  case  : 

P ,  aged  47,  at  the  time  of  coining  under  observation,  was  a  man  of  good  consti- 
tution, noted  for  his  strength  and  endurance,  but  for  three  years  he  had  not  been  well, 
during  most  of  which  time  he  had  been  treated  by  different  phj'sicians  for  •'  rheumatism." 
He  was  addicted  to  venereal  excesses,  and  used  and  abused  alcohol  occasionally.  Many 
years  before  he  had  had  a  chancre;  but  had  not,  subsequently,  had  any  of  the  ordinary 
evidences  of  secondary  or  tertiary  syphilis.  He  had  first  suffered  from  darting  or  shoot- 
ing pains  in  his  feet  and  legs ;  soon  he  experienced  sensations  of  numbness  and  tingling 
in  his  feet,  and  later,  in  the  little  and  ring  fingers  of  the  left  hand.  For  a  short  time  he 
was  troubled  with  double  vision,  and  his  sight  had  diminished  a  little  in  acuteness. 

The  results  of  an  examination  made  during  the  first  week  he  was  under  observation 
were  as  follows  :  No  paralysis  was  made  out ;  galvanic  and  faradic  irritability  were  well 
preserved.     He  could  not  walk  well  after  dark.     He  swayed  and  tottered  on  trying  to 


LOCOMOTOR  ATAXIA — CEREBRAL  HYPEREMIA,  ETC.       545 

stand  with  his  heels  together,  or  with  his  eyes  shut ;  and  he  could  barely  manage  to 
stagger  a  few  steps  with  his  eyes  closed. 

Paroxysms  of  sharp,  sudden  pain  in  the  limbs  were  more  frequent.  He  was  awkward 
with  his  hands  in  dressing.  A  peculiar  sense  of  constriction  or  drawing  in  the  lower 
part  of  the  abdomen  had  annoyed  him  for  several  months ;  sexual  desire  had  diminished. 
He  had  no  delusions,  and  was  fully  able  to  attend  to  his  business,  which  required  a  large 
amount  of  physical  and  mental  exertion. 

Under  the  use  of  nitrate  of  silver,  galvanization  of  the  spine,  and  faradization  of  the 
extremities,  continued  for  several  months,  he  improved  remarkably;  but,  after  remaining 
better  for  a  few  months,  he  again  relapsed,  and  now  he  got  steadily  worse.  Occasionally, 
however,  he  would  temporarily  improve.  The  anaesthesia  of  his  feet  and  hands  deepened ; 
the  staggering  gait  returned  and  grew  worse ;  every  two  or  three  weeks  he  would  have 
frightful  attacks  of  lancinating  pains. 

Decided  mental  symptoms  first  began  to  make  their  appearance  two  years  after  first 
coming  under  treatment.  He  spent  his  money  very  freely  upon  others,  as  well  as  upon 
himself.  His  ideas  became  queer  and  lofty;  but  the  delirmm  of  grandeur  did  not  de- 
velop thoroughly  until  nearly  a  year  later,  when  he  began  to  talk  and  act  in  the  most  pre- 
posterous manner.  About  the  same  time  a  peculiar  stagger  in  his  speech,  a  slight  twist- 
ing of  the  mouth  to  one  side,  and  some  tremor  of  the  tongue  and  lips  became  noticeable 
when  he  talked. 

Nearly  three  years  after  the  notes  first  made,  and  almost  six  years  after  the  develop- 
ment of  ataxic  pains,  he  was  sent  to  the  insane  department  of  the  Pennsylvania  Hospital, 
where  Dr.  Mills  occasionally  visited  him. 

His  delirium  became  of  the  wildest  character,  and  he  became  irritable  and  hard  to 
manage.     Anaesthesia  and  tremor  of  tongue  increased. 

On  two  occasions  he  had  slight  apoplectiform  attacks,  once  accompanied  by  a  slight 
spasm. 

Later  he  was  removed  to  the  State  Hospital  for  the  Insane  at  Danville,  Pennsylvania, 
where  he  remained  until  his  death,  which  occurred  five  years  and  four  months  after  first 
coming  under  care  of  Dr.  Mills,  and  about  eight  years  after  he  was  first  affected  with 
ataxic  pains.  A  post-mortem  examination  of  the  brain  and  spinal  cord  was  made.  The 
pia  mater  over  both  cerebral  hemispheres,  particularly  in  the  postero-frontal  and  parieto- 
temporal regions,  was  opaque,  congested,  and  adherent  at  points;  decortication  being 
marked.  Convolutions  were  atrophied.  The  pia  mater  of  the  cerebellum,  especially 
over  the  superior  vermiform  process,  was  deeply  congested  and  adherent.  The  pia  mater 
of  the  spinal  cord  was  thickened,  and  the  cord  presented  an  irregularly  shrunken  appear- 
ance. 

Microscopic  examination  showed  marked  sclerosis  of  the  posterior  columns  of  the 
spinal  cord  throughout  its  whole  extent,  and  that  inflammation  and  thickening  of  the  pia 
mater  were  also  present  everywhere.  The  sclerosis  was  most  pi'onounced  in  the  lumbar 
region,  decreasing  in  intensity  as  the  cord  was  ascended  ;  but  it  was  well-marked  through- 
out, both  in  the  columns  of  GoU  and  in  the  posterior  root  zones. 

The  medulla  oblongata  on  one  side  was  much  sclerosed,  and  slightly  so  on  the  other. 
Sclerosis  was  also  present  in  the  pons,  crura,  optic  thalami,  and  convolutions  examined, 
and  in  the  cerebellum.  The  pathological  appearance  shown  by  the  microscope  corre- 
sponded closely  to  those  mentioned  by  Westphal  as  occurring  in  the  spinal  cord  in  de- 
mentia paralytica.  According  to  him,  the  posterior  columns  show  few  or  no  sections 
of  nerve  fibres,  and  their  place  is  taken  by  a  connective  tissue  substance.  In  the  cervical 
region  Goll's  cuneiform  columns  are  especially  affected  ;  in  the  dorsal  and  lumbar  regions, 

35 


54^  PSYCHOLOGICAL   MEDICINE. 

however,  the  entire  area  of  the  posterior  columns  is  involved.  In  fresh  preparations, 
numerous  granular  fat-cells  and  corpora  amylacea  are  found. 

In  this  case  the  spinal  symptoms  were  the  first  to  appear.  Three  )-ears  before  coming 
under  the  care  of  Dr.  Mills  he  began  to  suffer  with  the  lancinating  pains  of  posterior 
sclerosis.  Although  when  first  seen  by  him,  and  until  he  improved  under  treatment,  he 
suffered  at  times  from  mental  anxiety  and  sleeplessness,  apparently  the  result  of  the  pain 
and  other  distressing  symptoms  of  the  ataxia,  no  typical  mental  symptoms  appeared  until 
more  than  two  years  later,  and  more  than  five  years  after  the  appearance  of  the  first  symp- 
tom of  spinal  trouble. 

Dr.  Mills  referred  to  the  views  of  various  authorities  with  reference  to  the  relation  of 
locomotor  ataxia  and  general  paralysis  of  the  insane.  According  to  Westphal,  with  whom 
Hammond  agrees,  no  direct  relation  exists  between  the  morbid  process  in  the  cord  in  pos- 
tenor  spinal  sclerosis,  and  that  in  the  brain  in  general  paralysis  of  the  insane.  Accord- 
ing to  these  authorities  neither  disease  is  secondary  to  the  other.  They  simply  coexist  as 
the  expression  of  an  excessive  proclivity  to  diseases  of  the  nervous  system,  just  as  any 
other  two  diseases  may  be  present,  one  in  the  brain  and  the  other  in  the  cord,  without  there 
being  any  direct  interdependence  between  them.  Locomotor  ataxia  is  by  no  means  un- 
common in  patients  affected  with  the  other  forms  of  insanity. 

Hamilton  {^New  York  Medical  Record,  July  29,  1876),  discusses  the  relation  of  these 
two  affections.  Leidesorf  has  related  one  case  in  which  general  paralysis  was  preceded 
by  spinal  symptoms.  Maudsley  speaks  of  other  cases.  Calmiel  says  that,  in  many  cases, 
the  changes  proceed  from  the  cord  upward,  and  Baillarger  indorses  his  views.  Charcot 
has  proved,  very  conclusively,  that  disseminated  sclerosis  can  exhibit  all  the  symptoms  of 
general  paralysis  of  the  insane. 

Cases  reported  by  Obersteine,  Hamilton,  Plaxsen,  Mickle,  and  others,  were  also  re- 
ferred to. 


CHAPTER  XXX. 

ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM. 

We  have  three  kinds  of  electricity  at  our  disposal  in  the  treatment 
of  nervous  and  mental  diseases, — the  constant  or  galvanic  current, 
the  induced  or  faradic  current,  and  static  electricity.  In  the  former, 
the  constant  current,  we  have  a  means  more  powerful  than  any  other 
of  modifying  the  nutritive  conditions  of  the  central  nervous  system. 
It  possesses  great  efficiency  to  antagonize  the  various  congestive 
states  of  the  brain  in  nervous  and  mental  disorders,  and  in  incipient 
insanity.  By  its  use  we  are  enabled  to  secure  a  proper  tonic  con- 
traction to  cerebral  bloodvessels  habitually  dilated,  and  we  can  also 
antagonize  by  its  use  the  symptoms  of  failing  memory,  weakened 
power  of  attention,  and  vertiginous  sensations,  if  we  use  it  daily  for 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  547 

some  time  to  the  head,  avoiding  injuriously  strong  currents.  The 
gravest  disorders  of  the  nervous  system  commence  often  with  hyper- 
semia  of  the  brain  and  cord,  which  ends  in  psychical  disorders  of 
varied  nature,  and  this  hypersemia  we  can  effectually  remove  by  the 
application  of  the  constant  current  to  the  brain.  Grave  brain  ex- 
haustion and  the  mental  and  nervous  debility  of  overworked  busi- 
ness and  professional  men  will  yield  rapidly  to  electricity  in  this  forrri 
and  to  centric  galvanization,  using  the  negative  electrode  at  the  pit  of 
the  stomach  while  the  positive  pole  is  applied  to  the  crown  of  the 
head  or  cranial  centre,  the  cervical  sympathetic  nerve  on  each  side  of 
the  neck  in  front  of  the  sterno-cleido-mastoid  muscle,  and  on  either 
side  of  the  sixth  and  seventh  cervical  vertebrae. 

It  is  but  a  short  time  since  I  discharged  from  treatment,  com- 
pletely cured,  a  young  merchant  of  New  York,  who  was  in  the  in- 
cipient stage  of  insanity.  The  bloodvessels  of  the  dura  mater,  the 
pia  mater,  and  of  the  brain  itself,  I  considered  in  this  case  to  be 
probably  habitually  dilated,  causing  marked  congestion  or  hyper- 
semia, and  the  indications  for  treatment  were  to  secure  a  tonic  con- 
traction of  these  vessels.  I  used  a  galvanic  battery  with  clock 
machinery  attached  to  it — a  balance  clock — the  isochronous  beats  of 
which  establish  and  interrupt  the  communication  between  the  poles 
at  intervals  of  fifteen  seconds.  The  galvanic  current,  when  slowly 
interrupted  in  this  way,  produces  a  more  energetic  contraction  of  the 
cerebral  bloodvessels  than  when  it  is  not  interrupted.  The  positive 
pole  I  placed  at  the  level  of  the  first  cervical  vertebra,  and  the  nega- 
tive pole  at  the  level  of  the  superior  ganglia  of  each  of  the  cervical 
sympathetic  nerves  in  turn.  The  sittings  lasted  five  minutes  each 
time.  Beyond  this  electrization  of  the  brain  I  did  nothing  beyond 
prescribing  a  course  of  warm  baths  at  bedtime,  with  a  dose  of  thirty 
grains  of  sodium  bromide  and  thirty  drops  of  cannabis  indica  in  half 
a  glass  of  water  after  the  bath,  and  friction  with  flesh  gloves  over 
the  whole  surface  of  the  body.  In  the  inception  of  treatment  I  also 
cleared  out  the  system  by  a  mercurial  cathartic,  followed  by  salines, 
which  is  an  excellent  preparatory  method  of  treatment  in  the  incipi- 
ent stages  of  mental  disorder.  Each  seance  produced  a  marked 
and  immediate  amelioration,  lasting  longer  and  longer  each  time, 
and  my  patient  described  a  sense  of  weight  as  lifting  from  the  verti- 
cal region  of  the  head,  at  which  point  he  had  persistent  headache, 
which  had  lasted  for  months, 

I  could  recount  many  similar  cases,  if  necessary,  but  the  above  is 


548  PSYCHOLOGICAL    MEDICINE. 

a  typical  one,  in  which  we  find  our  patient  restless,  sleepless,  and 
with  eyes  suffused  and  conjunctiva  congested,  and  confusion  of  mind. 
The  grave  cases  of  neurasthenia,  associated  with  cerebral  hypersemia, 
exhibit  impaired  nutrition  and  assimilation,  impaired  intellection, 
melancholia,  mental  depression,  muscular  atonicity,  irritability,  and 
inability  to  bear  stimulants  without  distress  in  the  head.  These 
patients  exhibit  morbid  psychical  symptoms  and  get  up  a  religious 
melancholy, — if  naturally  of  religious  tendencies, — and  there  is  often 
a  change  in  the  sentiment.  In  female  patients  there  is  menstrual 
suppression,  but  local  treatment  is  not  called  for  here,  as  electricity 
and  the  proper  constitutional  treatment  will  cure  the  patient.  Sleep- 
lessness, perspiration,  and  a  loss  of  the  elasticity  of  the  skin  are  all 
present  in  these  cases. 

Professor  Roberts  Bartholow  speaks  thus  respecting  the  influence 
of  the  galvanic  or  constant  current  in  affecting  the  brain  and  cord : 
"  Galvanism  can  alone  be  used  to  affect  the  condition  of  the  brain 
and  spinal  cord.  Faradism  does  not  pass  the  barrier  of  the  bony 
envelope  of  these  parts,  but  galvanism  has  been  experimentally  shown 
to  do  so.  That  galvanism  and  not  faradism  should  be  used  when  it 
is  proposed  to  reach  these  parts,  seems  therefore  conclusive.  There 
can  be  little  question  that  galvanism  is  highly  serviceable  in  certain 
vascular  states  of  the  intracranial  organs.  We  must  bear  in  mind 
how  galvanism  affects  the  vessels  in  order  to  apply  it  correctly.  We 
possess  no  agents  which  can  act  on  the  contractility  of  the  vessels 
with  the  promptness  and  efficiency  of  galvanism." 

By  securing  a  proper  tonic  contraction  to  cerebral  bloodvessels 
habitually  dilated,  Vv^e  ward  off  mental  disease  in  a  great  many  in- 
stances. We  should,  I  think,  use  the  positive  pole  of  the  constant 
current  at  the  level  of  the  first  cervical  vertebra,  and  the  negative 
pole  at  the  level  of  the  superior  ganglia  of  one  of  the  cervical  sympa- 
thetic nerves.  The  current  should  be  frequently  interrupted,  for 
experiments  show  that*  vascular  contraction  is  produced  most  mark- 
edly at  the  opening  and  closing  of  the  circuit.  The  number  of  cells 
employed  must  vary  with  the  constitutional  susceptibility  of  indi- 
viduals. Other  therapeutical  applications  of  the  constant  current 
are  used  to  suit  different  symptoms  in  different  cases. 

The  experiments  of  Ch.  Latournian,  of  France,  on  the  application 
of  the  galvanic  current  to  the  brain  and  its  membranes  are  very  con- 
clusive and  easy  to  verify.  A  kitten  is  taken  about  one  month  old, 
in  which  the  cranial  wall  is  still  very  thin  and  easy  to  cut,  and  a  por- 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  549 

tion  on  the  left  side  is  cut  out,  exposing  the  dura  mater.  It  will  then 
be  very  easy  to  see  with  the  naked  eye,  or  with  a  magnifying  glass, 
the  arterial  and  venous  branches  which  ramify  upon  the  surface. 
The  positive  pole  of  the  galvanic  current  is  then  to  be  placed  behind 
the  right  ascending  ramus  of  the  inferior  maxilla,  and  the  negative 
pole  upon  the  anterior  cranial  region,  above  the  eyes.  Twelve  sec- 
onds after  the  closing  of  the  circuit  the  periarterial  branchings  of 
the  dura  mater  become  less  and  less  visible,  and  a  little  later  the 
venous  branches  themselves  become  pale.  At  each  interruption  of 
the. current  the  anaemia  increases  for  an  instant  and  then  the  vessels 
grow  a  little  larger.  This  experiment  can  be  repeated  as  often  as 
necessary,  and  will  always  give  the  same  results.  The  dura  mater 
may  then  be  cut  out  and  the  pia  mater  exposed,  when  its  vascular 
branches — arterial  and  venous — will  be  visible  upon  the  gray  ground 
of  the  cerebral  substance.  The  same  observations  may  be  made  on 
it  as  on  the  dura  mater,  and  with  the  same  results,  of  obtaining  at 
will  a  contraction  of  the  cerebral  vessels. 

The  therapeutic  value  and  practical  bearing  of  these  facts,  as 
applied  to  diseases  of  the  nervous  system  and  to  psychological 
medicine,  are  immense.  About  the  only  medicines  that  we  need  to 
employ  with  cephalic  electrization,  are  the  sodium  bromide  and 
cannabis  indica  mixture,  referred  to  before  in  this  volume,  which  I 
claim  is  the  most  valuable  combination  to  soothe  and  tranquillize  the 
cerebral  nervous  system  that  the  general  practitioner  possesses  in 
the  incipient  stages  of  insanity,  and  very  many  cases  might  be  cured 
in  their  own  homes  without  ever  going  to  an  asylum  by  this  treat- 
ment, conjoined  with  perfect  rest.  30  grains  of  bromide  of  sodium, 
and  30  minims  of  a  reliable  tincture  of  cannabis  indica,  thrice  daily, 
in  water,  is  the  minimum  dose,  while  the  maximum  dose  is  60  grains 
of  the  sodium  bromide  and  60  drops  of  the  tincture  of  cannabis 
indica;  while  to  prevent  brain-wasting,  and  as  a  general  tonic  to  the 
exhausted  nervous  system,  Routh's  formula  of  the  chloro-phosphide 
of  arsenic,  commencing  with  5-minim  doses  and  gradually  decreasmg^ 
is  an  excellent  adjunct.  The  value  of  arsenic  as  a  nerve-tonic  of 
great  efficacy  is  not  thoroughly  appreciated  by  the  profession  at 
large.  The  subject  of  the  electro-therapeutics  of  the  diseases  of  the 
nervous  system  is  full  of  interest.  The  constant  current  is  extremely 
useful  in  antagonizing  pain,  and  is  sedative,  restorative,  and  refreshing 
in  its  action.  I  have  found  it  of  the  greatest  use  in  neuralgia  of  the 
solar  plexus,  the  cardiac  plexus,  in  gastrodynia,  and  in  ovarian  neu- 


5 so  PSYCHOLOGICAL   MEDICINE. 

ralgia.  I  always  put  the  electrode  of  the  positive  pole  over  the  seat 
of  pain,  and  the  negative  either  on  the  spinal  cord  or  at  some  indif- 
ferent spot.  I  have  seen  ovarian  neuralgia  of  extreme  intensity, 
which  had  resisted  any  safe  amount  of  morphia  and  atropia  hypo- 
dermically,  give  way  to  the  galvanic  current  when  a  current  from 
thirty-two  cells  was  applied  locally  to  the  abdominal  region.  Centric 
galvanization,  which  affects  the  brain,  spinal  cord,  and  cervical  sym- 
pathetic and  pneumogastric  nerves,  gives  us  the  most  powerful  tonic 
and  reconstituent  means  at  our  command  over  the  whole  central 
nervous  system ;  while,  to  promote  greater  activity  in  the  nutritive 
functions  generally,  we  can,  by  the  proper  and  judicious  use  of  the 
faradic  current  of  electricity,  exercise  all  of  the  muscles  of  the  body 
daily  and  improve  nutrition  very  markedly.  The  galvanic  current, 
however,  possesses  much  more  power  over  the  nutrition  of  organs 
and  tissues,  owing  to  its  action  on  the  circulation.  In  the  amyo- 
trophic paralysis  from  disease  of  the  anterior  cornua  of  the  spinal 
cord,  where  the  muscles  waste  very  rapidly,  if  we  do  not  arrest  the 
trophic  degeneration,  we  shall  find  very  probably  the  reactions  of 
degeneration,  so  that  there  is  no  contractility  of  the  paralyzed  mus- 
cles, as  in  infantile  paralysis,  to  the  induced  or  faradic  current.  The 
galvanic  current,  both  in  these  cases  and  also  in  facial  paralysis,  will 
cause  movements  of  the  muscles,  and  we  have  to  use  this  current, 
therefore,  until  the  contractility  of  the  faradic  current  is  restored, 
and  until  the  muscles  have  recovered  their  normal  volume  and  con- 
tractility. In  hemiplegia,  if  electro-contractility  is  not  lost  and  the 
muscles  not  wasted,  electricity  need  not  be  used  at  all.  In  paraple- 
gia, if  the  lesion  is  above  the  dorso-lumbar  enlargement  of  the  cord, 
electro-contractility  is  preserved;  if  the  lesion  is  at  the  nerve-centres, 
or  the  dorso-lumbar  enlargement,  we  get  the  reactions  of  degenera- 
tion and  loss  of  electro-contractility,  and  must  then  use  slow  inter- 
ruption of  the  galvanic  current.  In  the  treatment  of  sciatica,  in 
common  with  other  neuralgias,  it  is  important  to  bear  in  mind  that 
pathological  causes  which  irritate  the  ner\-e  high  up  in  the  trunk, 
produce  pain  at  the  peripheric  distribution,  and  sensations  excited 
by  irritation  of  the  origin  or  nucleus  of  a  sensory  nerve  are  uniformly 
referred  to  the  periphery.  The  great  predisposing  cause  of  sciatica, 
in  common  with  the  other  neuralgias,  is  hereditary  predisposition, 
which  results  in  the  transmission  of  an  imperfect  nervous  system, — a 
neurotic  constitution.  Sciatica  is  one  of  the  most  curable  of  neural- 
gias, if  properly  treated.     If  injudiciously  treated,  it  is  often  very 


ELECTRICITY    IN    DISEASES    OF   THE   NERVOUS    SYSTEM,  55 1 

intractable.  We  have  as  forms  of  sciatica,  aside  from  a  simple 
neuralgia,  syphilitic  and  rheumatic  forms  of  the  disease,  the  former 
.occurring  very  frequently;  and  in  obstinate  cases,  which  have  resisted 
all  other  treatment,  we  may  get  brilliant  cures  by  giving  iodide  of 
potassium  in  combination  with  small  doses  of  bichloride  of  mercury. 
The  irritation  set  up  by  obstinate  constipation,  the  puerperal  state, 
where  the  enlarged  uterus  produces  an  irritative  pressure,  or  a  tumor 
pressing  on  the  nerves  in  the  pelvis,  may  all  cause  sciatica.  The 
worst  cases  we  meet  with  in  practice  occur  between  forty  and  fifty 
years  of  age.  Primarily,  rest  is  the  great  therapeutic  agent.  Our 
patient  must  not  be  allowed  to  walk,  as  muscular  movements  are 
very  injurious,  as  the  nerve  is  pulled  upon  by  the  muscles  and  the 
pain  thus  aggravated.  The  patient  must  also  be  kept  warm,  and 
wear  silk  drawers  if  he  can  afford  silk  underclothing,  and  the  bowels 
kept  carefully  regulated.  When  the  paroxysms  of  pain  come,  we 
may  alleviate  them  temporarily  by  hypodermics  of  morphia  and 
atropia,  and  we  may  paralyze  the  sensibility  of  the  peripheral  nerves 
by  local  application  of  aconite  liniment  or  cyanide  of  potassium,  as 
spoken  of  in  the  chapter  on  neuralgia.  The  use  of  the  constant 
current  of  electricity,  by  its  stimulating  and  catalytic  effects,  will 
enable  us  to  get  that  perfect  cure  which  should  be  our  aim.  The 
negative  pole  of  a  battery  of  thirty-two  cells  should  be  placed  oppo- 
site the  roots  of  the  nerves  which  form  the  sciatic,  and  the  positive 
pole  is  applied  at  the  seat  of  pain,  I  make  this  application  twice 
daily,  and,  by  keeping  up  the  nutrition  of  the  central  nervous  system 
at  the  same  time,  I  obtain  the  most  gratifying  results  even  in  cases 
of  years'  standing.  The  nutrition  of  the  sciatic  nerve  is  much  im- 
proved, and  there  is  a  healthy  change  induced  in  the  entire  nerve. 
I  have  also  cured  some  cases  of  sciatica  by  static  electricity,  using 
the  Touplar  or  improved  Holtz  machine,  charging  the  patient,  and 
then  drawing  powerful  sparks  along  the  course  of  the  affected  nerve 
by  the  wire  brush  or  other  electrode.  If  we  wish  to  be  successful 
with  static  electricity,  we  must  have  great  tension  and  quantity.  In 
severe  lumbago,  affecting  the  dorsal  muscles  and  the  intercostals, 
with  severe,  excruciating  pains,  making  the  patient  bend  almost 
double,  I  have  experienced  uniformly  good  results  in  every  case  from 
the  use  of  the  constant  current  to  the  affected  region,  together  with 
slight  ether  inhalations.  We  certainly  get  a  specific  effect  from  the 
use  of  the  constant  current  in  nearly  all  the  neuralgias,  and  static 
electricity  from  a  good  machine  will,  from  the  stimulating  effects  of 


552  PSYCHOLOGICAL    MEDICINE. 

a  thick  spark  on  the  deep  tissues,  also  give  good  results.  In  facial 
neuralgia  the  constant  current  is  very  useful.  In  paralysis  from 
brain  disease,  particularly  in  hemiplegic  cases  where  we  find  absence 
of  any  decided  mental  disturbance,  slight  thickness  of  speech,  more 
or  less  deviation  of  the  tip  of  the  tongue  to  the  paralyzed  side  when 
it  is  protruded,  partial  and  incomplete  paralysis  of  the  facial  muscles 
on  the  side  on  which  the  paralysis  of  the  limbs  exists,  more  or  less 
complete  loss  of  voluntary  power  over  the  left  arm  and  leg,  if  the 
lesion  is  in  or  near  the  right  corpus  striatum,  loss  of  sensibility  and 
numbness  on  the  paralyzed  half  of  the  body,  and  slight  elevation  of 
temperature  on  the  paralyzed  side,  if  the  contractility  of  the  muscles 
be  peifect,  the  use  of  electricity  is  coiitraindicated. 

When,  in  paralysis,  we  meet  with  the  reactions  of  degeneration, 
wasting  of  muscles,  or  loss  of  normal  muscular  irritability  or  con- 
tractility, the  galvanic  or  constant  current  is  then  indicated,  and  after 
we  get  by  this  current  an  irritability  which  responds  to  the  induced 
or  faradic  current,  we  may  proceed  with  that  current  to  the  ultimate 
restoration  or  cure  of  the  paralysis.  In  hysterical  paralysis,  where 
the  patient  has  no  zvill  to  move  her  muscles,  we  may  get  a  rapid  and 
brilliant  cure  by  the  induced  current,  or  by  static  electricity.  In 
neuralgia  or  hyperaesthesia  of  the  testes,  which  is  a  very  painful  neu- 
rosis, we  have  a  perfect  means  of  relief  in  the  constant  current  of 
electricity,  conjoined  with  laxatives,  followed  by  tonics. 

In  hyperaesthesia  or  irritable  state  of  the  uterus,  a  very  trouble- 
some neurosis,  we  apply  a  cup-shaped  electrode,  attached  to  the 
negative  pole,  to  the  os  uteri,  and  the  positive  to  the  hypogastric  or 
sacral  region,  with  uniform  good  results.  A  very  good  local  seda- 
tive consists  of  5j  of  morphia  to  oj  of  unguentum  belladonnse,  and 
a  little  pill  of  this  rolled  up  and  introduced  into  the  os.  This  is  also  a 
very  valuable  remedy  in  hysteria.  The  patient  can  hardly  sit  down, 
and  coition  is  impossible  in  true  hyperaesthesia  of  the  uterus.  It 
results,  I  think,  from  neurasthenia. 

Nervous  cardiac  pain  near  the  apex  of  the  heart  is  a  common  and 
distressing  neurosis,  and  this  cardiac  irritability  is  alleviated  by  cen- 
tric galvanization.  This  form  of  application  also  relieves  neuralgia 
or  hyperaesthesia  of  the  stomach,  in  which  the  vasomotor  nerves 
and  the  tone  of  the  arteries  are  impaired.  Spinal  hyperaesthesia  is 
also  very  amenable  to  treatment  by  the  constant  current.  We  al- 
ways find  that  neurotic  pains  of  the  spine  are,  as  a  rule,  much  more 
severe  than  those  accompanying  serious  organic  trouble.     Neuralgia 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  553 

or  hypersesthesia  of  the  breast  in  women  is  readily  cured  by  the 
judicious  use  of  the  constant  current. 

In  cerebrasthenia  or  nervous  prostration,  we  have  a  hypersesthesia 
or  neuralgia  of  the  entire  brain.  This  condition  may  lead  to  insanity 
if  not  checked,  and  cephalic  electrization  is  our  most  important  thera- 
peutic measure.  The  brain  is  enfeebled  and  hyperaesthetic,  and  the 
daily  use  of  cephalic  electrization  will  soon  improve  its  nutrition 
and  tone,  and  we  shall  cure  our  patient.  In  all  cases  we  must  build 
up  and  improve  the  nutrition  of  the  central  sensory  nerve-cells,  as  it 
is  this  condition  of  imperfect  nutrition  which  causes  neuralgia  and 
hypersesthesia.  In  the  early  stage  of  progressive  or  general  paraly- 
sis, we  may  sometimes  gain  great  benefit  from  centric  galvanization, 
and  cut  off  the  wearing  impressions  which  are  transmitted  practically, 
without  cessation,  to  the  brain. 

In  using  electricity,  we  should  remember,  in  contracted  muscles, 
to  apply  the  faradic  current  to  the  antagonistic  or  extensor  muscles, 
and  use  the  galvanic  current  to  the  flexor  muscles.  In  this  way  we 
may  successfully  treat  the  late  rigidity  of  hemiplegia. 

In  infantile  paralysis,  the  electro-contractility  is  diminished,  the 
muscles  waste  and  undergo  fatty  degeneration,  and  are  affected  by 
secondary  contractures.  They  will  not  react  to  the  faradic  cur- 
rent, but  will  to  the  interrupted  galvanic  current,  and  are  very 
sensitive  to  it,  therefore  we  must  first  use  this  and  afterwards  the 
faradic  current.  As  long  as  there  is  response  to  the  faradic  current, 
we  should  use  it  in  preference.  We  must  not  use  electricity  too 
soon  in  paralysis  from  cerebral  disease,  and  the  same  remark  applies 
to  strychnia. 

As  I  have  previously  stated,  the  amount  of  contractility  will 
show  us  how  much  good  electricity  will  do.  If  it  is  normal,  elec- 
tricity will  do  no  good;  while  if  the  electro-contractility  is  markedly 
impaired,  much  good  may  be  done  by  it.  In  all  cases  we  may  im- 
prove the  nutrition  of  the  muscular  system.  As  a  general  rule,  we 
must  treat  the  muscles  by  the  current  to  which  they  will  most 
readily  respond.  In  paraplegia  from  myelitis,  meningitis,  or  hsem- 
orrhage  into  the  cord,  electricity  must  not  be  used  while  the  active 
lesion  exists.  We  may  then — after  the  active  lesion  has  subsided — 
use  the  interrupted  constant  current  until  the  farado- contractility  is 
restored,  and  the  faradic  current,  or  both  combined.  In  gunshot 
wounds  and  injuries  of  nerves,  followed  by  paralysis,  faradization  is 
invaluable.     In  local  paralysis  from  cold,  or  lead-poisoning,  we  use 


554  PSYCHOLOGICAL    MEDICINE. 

the  interrupted  galvanic  current,  and  subsequently  the  two  forms 
combined.  Galvanism  is  also  very  useful  in  atonic  dyspepsia, 
writer's  cramp,  muscular  atrophy,  spinal  irritation,  aphonia,  insomnia, 
diphtheritic  paralysis,  locomotor  ataxia,  paralysis  agitans,  myalgia, 
impotence,  epileptiform  neuralgia,  torticollis,  etc. 

The  good  effects  of  electricity  in  nervous  diseases  is  readily  un- 
derstood when  we  reflect  upon  the  influence  of  the  sympathetic  or 
ganglionic  nervous  system  on  the  vascular  system,  and  secondarily 
on  blood,  nutrition,  and  secretion,  and  also  its  influence  on  thoracic, 
abdominal,  and  pelvic  viscera,  except  the  vascular  system. 

When  the  cervical  sympathetic  is  galvanized  in  the  neck,  the  pupil 
dilates  and  there  is  contraction  of  the  bloodvessels  of  the  correspond- 
ing side  of  the  head,  and  a  diminution  of  the  temperature,  if  this 
had  previously  been  raised  by  section  of  the  nerve.  There  is  dimin- 
ished supply  of  blood,  and  diminished  temperature.  By  the  use  of 
electricity  we  affect  the  circulation  very  powerfully,  as  it  is  under  the 
control  of  the  central  nervous  system,  which  we  act  directly  upon 
by  the  electric  current  in  two  ways,  first,  through  the  vasomotor 
nerves,  and  second,  through  the  cardiac  branches  of  the  sympathetic 
and  pneumogastric  nerves ;  we  also  influence  powerfully  the  excita- 
bility and  vitality  of  the  parts  owing  to  the  control  which  the  sympa- 
thetic, through  its  vasomotor  action,  has  over  these  processes.  The 
action  of  electricity  over  the  abdominal  and  pelvic  viscera  is  through 
its  action  on  the  branches  of  the  sympathetic  distributed  to  the  se- 
creting organs  to  regulate  the  supply  of  blood,  and  control  their  ac- 
tivity, while  for  the  intestines  and  genito-urinary  apparatus,  it  stimu- 
lates peristaltic  action  or  simple  contraction.  By  galvanization  of 
the  solar  plexus  we  can  effect  peristaltic  movements  of  the  large  intes- 
tines. I  think  that  galvanism  may,  as  it  is  used  mildly  or  energeti- 
cally, either  exalt  or  depress  the  functions  of  the  nervous  centre  on 
which  it  acts.  I  cannot  explain  the  reason  of  this,  unless  it  depends 
upon  the  ganglionic  centres  through  which  the  electricity,  analogous 
to  nervous  force,  passes  before  it  reaches  the  final  distribution  of  the 
nerves  to  the  contractile  or  secreting  elements.  Charcot  considers 
that  static  electricity  is  very  useful  in  hysterical  and  hystero-epileptic 
cases,  in  peripheric  facial  paral3'-sis,  paralysis  agitans,  spinal  irritation, 
dyspepsia  and  dysmenorrhoea ;  cutaneous  anaesthesia,  the  numbness 
and  anaesthesia  of  hemiplegia,  paraplegia,  neuralgia,  and  rheumatic 
affections,  are  also  favorably  influenced  by  the  stimulation  of  the  pe- 
ripheral nerves  by  the  electric  spark,  spray,  or  electric  wind  of  the  im- 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM. 


555 


proved  Holtz  machine.  We  also  get  sedative  and  tonic  effects  from 
static  electricity.  We  can  also  get  muscular  contraction  with  less 
pain  with  the  induced  current.  We  insulate  our  patient  by  placing 
him  on  an  insulated  platform,  which  is  connected  with  one  pole  of  the 
machine,  and  then  either  treat  him  by  insulation  alone  for  the  simple 
tonic  effect  on  the  whole  nervous  system,  or  we  "  draw  "  sparks  by 
an  electrode  attached  to  an  earth  connection.  The  electrodes  are 
balls  of  metal  or  wood  for  the  spark,  the  electric  brush  for  the  elec- 
tric "  spray,"  or  a  metallic  sharp  point  for  the  electric  "  wind,"  all  on 
glass  handles.  We  use,  in  our  private  hospital,  for  nervous  and  men- 
tal diseases  a  large  improved  Holtz  machine  with  great  success,  a  cut 
of  which  we  give,  and  cordially  recommend  it  to  the  profession. 


The  faradic  or  induced  current  of  electricity  is,  when  used  as 
general  faradization,  a  general  muscular  and  nerve  tonic.  It  should 
never  be  used  sufficiently  strong  to  be  disagreeable  to  the  patient.  I 
apply  the  negative  pole  to  the  coccyx,  and  then  apply  the  positive  pole, 


55^  PSYCHOLOGICAL    MEDICINE. 

using  a  sponge  electrode,  to  the  top  of  the  head  or  "  cranial  centre," 
to  the  cervical  sympathetic  nerve  in  the  neck,  and  on  each  side  of 
the  sixth  and  seventh  cervical  vertebrae,  and  finally  up  and  down 
the  spine.  I  also,  in  nervous  exhaustion  of  women,  have  the  entire 
surface  of  the  body  rubbed  with  the  positive  pole  to  which  is  attached 
a  broad  sponge  electrode,  by  an  experienced  nurse,  so  as  to  exercise 
the  fibrillae  of  each  individual  muscle,  an  electro-massage. 

Respecting  the  clinical  uses  and  forms  of  electricity,  Dr.  J.  Rus- 
sell Reynolds,  F.R.S.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  University  College,  says : 

With  regard  to  treatment  by  electricity,  I  have  a  few  general  remarks  to  make.  You 
can  sometimes  actually  and  immediately  cure  a  patient.  There  are  cases  in  which  the 
only  symptom  that  may  be  presented  to  you — I  do  not  say  the  whole  morbid  condition, 
but  the  only  symptom — is  loss  of  voice.  Sometimes  one  single  application  of  electricity 
will  remove  it  completely,  and  in  that  instance  you  do  apparently  cure  the  patient.  There 
are  other  diseases  which  you  cannot  be  said  to  cure,  but  which  you  may  relieve  by  elec- 
tricity. By  its  application  you  may,  in  many  instances,  again  and  again,  relieve  pain; 
you  may,  in  like  manner,  relieve  spasm ;  or  you  may  slowly  diminish,  and  even  ultimately 
remove,  paralysis.  In  these  cases  you  assist,  by  electricity,  the  processes  which  lead  to 
the  removal  of  the  pain,  paralysis,  or  spasm  ;  you  put  the  patient,  by  electrical  appliances, 
into  a  better  position  to  improve,  or  be  cured  by  the  agencies  of  food,  medicines,  rest,  and 
time.  Lastly,  there  is  a  group  of  cases  in  which,  though  you  cannot  cure  or  even  re- 
lieve the  symptoms,  you  may  yet  arrest  the  progress  of  disease.  Sometimes,  for  exam- 
ple, in  a  child  with  so-called  "  essential  paralysis,"  you  may  prevent  deformity,  though 
you  cannot  cure  the  paralysis.  In  certain  cases  of  lead-poisoning,  muscular  atrophy, 
etc.,  although  you  cannot  recall  the  muscular  substance,  you  may  prevent  the  atrophy 
from  increasing. 

I  think  it  is  necessary  for  me  to  say  a  few  words  as  briefly  as  possible,  about  the  sev- 
eral forms  of  electricity  which  are  now  in  common  clinical  use.  You  constantly  hear  of 
"  faradization,"  "  electrification,"  "galvanism,"  and  so  on;  of  "  battery-current,"  "  con- 
tinuous current,"  and  the  like ;  and  it  is  probable  that  some  of  you  may  not  have  perfectly 
clear  ideas  as  to  the  meaning  of  these  terms,  or,  at  any  rate,  ideas  which  are  precisely  the 
same  as  mine,  and  I  should  like  us  to  have  a  common  starting-point,  in  a  clear  compre- 
hension of  the  meaning  of  the  words  we  use. 

{a)  Many  years  ago,  it  was  the  therapeutic  fashion  to  put  the  legs  of  patients  into  buck- 
ets of  torpedoes,  or  electric  eels ;  but  this  practice  has  become  obsolete,  and  there  are 
now  only  three  forms  of  electrical  appliance  in  common  clinical  use.  One  is  that  of  the 
old-fashioned  "  electrical  machine,"  either  a  cylinder  or  plate  of  glass,  which,  by  friction, 
produces  a  certain  amount  of  electrical  disturbance,  one  of  the  results  of  which  you  col- 
lect on  an  insulated  piece  of  brass  called  a  "  prime  conductor."  This  is  the  oldest  mode 
of  applying  electricity  which  is  now  in  force  in  our  hospitals.  In  the  present  day  it  is 
sometimes  called  "static"  electricity;  and  in  speaking  of  the  use  of  static  electricity, 
what  is  meant  is  that  the  person  is  charged,  like  that  "  prime  conductor,"  with  electricity 
of  that  particular  kind.  It  has  also  been  called  "  frictional  "  electricity,  from  the  mode 
of  its  production;  and  also  "  Franklinic  "  electricity,  or  "  Franklinism,"  in  memory  of 
the  individual  who — I  will  not  say  discovered  it,  but  who — made  out  more  about  it  than 
any  one  else  at  the  time  that  he  worked  at  the  subject. 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  55/ 

1.  There  are  three  modes  in  which  that  electricity  is  applied.  One  is  simply  to  make 
the  patient,  as  it  were,  a  part  of  the  prime  conductor,  and  charge  him  full  of  electricity. 
You  insulate  your  patient  by  placing  him  upon  a  glass-legged  stool,  taking  care  that  he 
is  not  in  contact  with  any  conducting  substance  ;  then  you  connect  him  by  a  brass  chain, 
by  his  own  hand,  or  by  any  other  mode  you  like,  with  the  prime  conductor;  you  set  the 
machine  in  action,  and  fill  him  full  of  electricity,  do  nothing  more.  That  is  the  simplest 
mode  of  applying  static  electricity.  In  certain  diseases  it  is  curious  what  this  will  do, 
without  putting  the  patient  to  the  least  discomfort.  Probably  the  only  thing  he  will  be 
conscious  of  is  that  his  hair  seems  to  be  "  standing  on  end;"  this'is  neither  painful  nor 
even  uncomfortable,  but  it  is  wonderful  how  much  that  simple  "  charging  "  a  patient  will 
effect  in  some  forms  of  disease.  I  have  known  it  absolutely  remove,  in  a  few  seconds,  a 
"tic"  that  had  lasted  for  days.  Pain  in  the  sciatic  nerve,  many  odd  and  disagreeable 
sensations,  unpleasant  flutterings  about  the  heart,  depending  on  weak  innervation,  and 
tremor  of  the  limbs,  may  all  be  removed  by  simply  "  charging  "  the  patient. 

2.  Another  mode  of  using  this  Franklinic  electricity  is  to  apply  a  "  spark"  to  a  particu- 
lar part.  You  may  have  a  movable,  insulated  brass  knob  in  connection  with  a  prime  con- 
ductor, and  you  direct  it  to  the  larynx,  or  some  other  part,  and  let  the  spark  go  into  the 
skin.  Or  you  may  put  the  patient  on  a  glass-legged  stool,  and  charge  him  or  her  in  the 
way  I  have  described,  and  take  a  spark  out  of  the  larynx  or  the  limb  with  your  knuckle 
or  with  a  rounded  knob.  In  some  cases  of  aphonia,  where  the  aphonia  depends  on  a 
special  condition,  you  may  insulate  the  patient  and  charge  him  with  electricity  without 
the  slightest  benefit ;  but  take  a  spark  out  of  the  larynx,  or  put  a  spark  in, — whether  posi- 
tive or  negative,  it  matters  not, — and  that  particular  condition  of  aphonia  may  be  cured 
directly.  This  I  have  known  to  occur  when  much  more  painful  processes  of  electrifica- 
tion had  been  previously  tried,  and  without  effect. 

3.  A  third  mode  of  using  Franklinic  electricity  is  that  of  sending  the  shock  from  a 
charged  "  Leyden  phial  "  through  the  part  that  you  wish  to  affect.  This  has  occasionally 
produced  curative  results  when  other  modes  have  failed  ;  and  it  is  in  obstinate  nervous 
aphonia  that  its  influence  has  been  the  most  distinctly  seen.  But,  short  of  being  hanged, 
I  do  not  imagine  that  anything  could  be  much  more  pleasant. 

[d)  The  next  form  is  what  has  been  called  galvanism.  It  is  the  form  of  which  one 
hears  so  much,  in  the  present  day,  under  the  name  of  the  "  continuous  current,"  or  "  bat- 
tery current,"  or,  as  it  has  been  sometimes  called,  with  a  Hibernian  misuse  of  words,  the 
"interrupted  continuous  current."  By  all  these  terms  is  meant  that  form  of  electricity 
which  is  developed  by  chemical  decomposition.  The  particulai-  form  of  battery  does  not 
matter,  so  far  as  the  quality  of  the  electricity  is  concerned.  Wherever  you  have  chemi- 
cal decomposition  in  progress,  there  also  is  some  electrical  change  going  on ;  and  the  only 
object  a  medical  electrician  has,  in  choosiirg  any  particular  form  of  battery,  is  to  catch 
the  electricity  as  best  he  may.  This  form  of  electricity  is  characterized  by  the  following 
features :  It  is  of  low  "  intensity,"  so  far  as  regards  its  action  upon  nerve  and  muscle, 
but  it  is  in  considerable  "  quantity,"  and  it  produces  "  chemical  "  results,  and  results  on 
temperature,  "thermic"  results,  that  are  not  approximated  by  the  Franklinic  electricity. 

I  am  not  now  going  to  describe  to  you  the  batteries,  of  which  there  are  numberless 
kinds.  The  choice  among  them  is  guided  chiefly  by  considerations  of  cheapness,  porta- 
bility, the  ease  with  which  the  machine  can  be  kept  continuously  in  order,  the  bulk  of  the 
battery,  and  the  readiness  with  which  its  strength  of  action  can  be  regulated.  What  you 
vs^ant  is  a  current  that  shall  play  evenly,  and  at  a  measurable  strength,  for  a  certain  length 
of  time.  It  is  convenient  to  have  a  battery  that  is  portable,  and  it  is  a  great  point  to  have 
one  that  does  not  require  everlasting  looking  after.  The  battery  in  our  electrical  room 
in  this  hospital  (Elliott's)  is  not  portable,  but  the  majority  of  our  patients  are  ;   it  will  act 


558  ■      PSYCHOLOGICAL    MEDICINE. 

very  steadily  for  three  or  four  months ;  it  is  tolerably  cheap ;  it  can  be  verj-  readily  put  in  work- 
ing order  by  a  person  who  does  not  need  a  great  amount  of  electrical  skill ;  and  you  can 
easily  regulate  the  strength  of  the  current  you  employ. 

1.  There  are  two  modes  in  which  this  kind  of  electricity,  or  galvanism,  is  used.  In 
one  of  them  the  current  is  "  continuous,"  in  the  other  it  is  not.  A  really  continuous  current 
may  be  passed  through  the  body,  or  part  of  the  body ;  and  this  is  accomplished  by  intro- 
ducing the  whole  or  a  portion  of  the  human  body  into  the  circle  of  the  battery,  and  then 
letting  the  current  play  through  it.  This  will  do  the  following  things  :  it  will  relieve 
spasm  of  certain  kinds ;  it  will  relieve  pain  of  certain  kinds,  and  this  sometimes  in  a  few 
seconds,  and  the  effect  is  as  obvious  and  distinct  as  is  that  following  the  administration  of 
an  emetic.  A  person  may  have  a  particular  kind  of  headache ;  you  pass  a  continuous  cur- 
rent, as  it  appears,  through  his  head,  and  sometimes  in  a  few  seconds  the  pain  is  gone. 
It  will  also  remove  some  forms  of  tremor  and  of  spasm. 

I  want  you  to  bear  in  mind  certain  points  respecting  the  effects  of  the  continuous  cur- 
rent upon  the  limbs,  according  to  the  direction  in  which  it  is  passed  thiough  those  limbs. 
Supposing  I  have  the  positive  end  of  the  battery  connected  with  a  person's  left  hand,  and 
the  negative  end  connected  with  his  right,  the  current,  passing  from  the  positive  to  the 
negative  pole,  goes  up  the  person's  left  arm  to  the  trunk  of  the  body,  and  down  the  right 
arm  to  the  machine  again.  The  cun-ent  passing  up  the  arm  has  been  called  the  "  inverse," 
and  that  coming  down  the  arm  has  been  called  the  "  direct."  In  the  arm  in  which  the 
current  is  passing  upwards  the  "  irritability  "  of  the  muscle  and  nerve  is  gradually  in- 
creased; in  the  other  arm,  in  which  the  current  is  passing  downwards,  the  irritability  is 
gradually  diminished.  You  may  test  this  fact  by  now  and  then  breaking  and  remaking 
the  continuous  current;  and  you  will  find  that  in  the  two  arms  two  different  degrees  of 
irritability  exist,  according  to  the  direction  in  which  the  current  had  been  passing,  whether 
up  or  down.  One  arm  will  act  more,  the  other  less  readily  than  in  health.  The  difference 
thus  produced  between  them  is  sometimes  highly  marked. 

It  may  occur  to  you  to  ask,  "  If  that  be  the  case,  which  current  should  I  use  to  relieve 
pain  and  spasm,  the  direct  or  the  inverse  ?"  All  I  have  to  say  is,  that  so  far  as  I  have 
seen,  it  does  not  make  the  smallest  difference.  Theoretically  it  should  make  a  very  great 
difference,  but  practically  it  makes  none.  I  have  seen  pain  or  spasm  relieved  as  well  by 
the  current  in  one  direction  as  in  the  other,  and  this  whether  the  spasm  has  been  clonic 
or  tonic,  or  whether  there  has  been  merely  tremor. 

The  continuous  current,  when  weak,  produces  little  or  no  pain.  The  patient  feels 
nothing,  or  next  to  nothing.  If  it  be  strong,  he  feels  a  tingling  or  burning  at  the  points 
of  contact,  and  a  sensation  of  lightness  and  tension  in  the  part,  between  the  points  of  con- 
tact, that  is  very  disagreeable,  or,  indeed,  intolerable. 

2.  Another  mode  of  using  the  battery  current  is  by  interruptmg  it — making  it  not  con- 
tinuous. This  may  be  done  in  various  ways.  You  may  take  the  two  sponges  attached 
by  wires  to  the  two  ends  of  the  battery,  place  one  sponge  on  the  upper  part  of  the  man's 
leg,  and  interrupt  the  current  by  occasionally  dabbing  the  other  sponge  on  the  leg  at  a 
more  or  less  distant  point.  By  that  means  you  "  make  "  and  "  break  "  the  current.  Or 
you  may  have  a  simple  piece  of  apparatus  attached  to  the  battery, — a  cogged  wheel,  with 
alternating  conducting  and  non-conducting  materials ;  which  wheel  can  be  rotated,  and 
so  interrupt  the  cuirent,  while  the  sponges  are  maintained  in  place.  Or  you  may  use  a 
little  vibrating  wire,  which  makes  and  breaks  contact  rapidly,  as  in  one  of  Pulvermacher's 
interruptors.  In  thus  applying  the  battery  current  you  will  notice  this  further  fact,  namely, 
that  the  "  direct  "  application  produces  more  obvious  effects  upon  the  muscles  (z.  e.,  in- 
duces a  more  marked  contraction)  than  does  the  "inverse"  or  "indirect."  You  will 
find,  for  example,  that  an  interrupted  batterry  current, — say  of  ten  cells, — which,  when 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  559 

sent  down  the  arm  produces  distinct  contraction  of  the  muscles,  may  elicit  no  contraction, 
or  very  much  less  contraction,  when  it  is  sent  up  the  arm  in  the  opposite  direction.  It 
is  important  to  bear  this  in  mind  when  thus  using  galvanism  for  the  purposes  of  either 
diagnosis  or  treatment,  as  I  shall  hereafter  show  you. 

(<r)  The  third  form  of  electricity  is  "  faradization,"  or  "  faradism."  It  has  also  been 
called  "  induced"  electricity,  "  magneto-electric,"  "  voltao-magnetic,"  "  voltao-dynamic." 
When  you  hear  used  any  one  of  these  words,  you  will  understand  by  them  that  particular 
kind  of  electricity  of  which  Faraday  was  the  great  exponent.  It  is  electricity  of  very  high 
tension,  and  resembles  more  closely  Franklinic  electricity  than  it  does  the  galvanic  cur- 
rent. The  chemical  action  of  faradization  is  almost  w?7/  the  direct  effect  on  temperature 
is  almost  7iil ;  it  causes  no  burning  feeling,  no  sensation  of  heat,  like  that  which  is  commu- 
nicated by  the  galvanic  current;  but,  under  ordinary  circumstances,  it  produces  marked 
contraction  of  the  muscles,  and  a  powerful  action  on  the  nerves  of  both  motion  and  sen- 
sation. It  is  an  "induced  "  current,  and  is  of  momentary  existence  only;  but  these  mo- 
mentary currents  may  be  repeated  slowly  or  repeated  quickly.  It  exists  only  at  the 
moment  of  making  or  breaking  the  galvanic  current,  or  at  the  moment  of  making  or  un- 
making a  magnetic  condition  in  a  piece  of  metal;  but  it  may  be  made  or  broken  so  rap- 
idly that  you  may  pass  very  many  currents  in  a  second  of  time  in  both  directions.  Re- 
member, lastly,  that,  though  it  is  of  momentary  duration,  it  is  of  very  high  tension. 

There  are  two  terms  used  commonly  about  it,  and  which  you  may  see  on  batteries  of 
various  kinds — "primary"  and  "secondary."  It  is  for  clinical  purposes  an  almost  use- 
less distinction.  The  difference  between  the  two  has  been  said  by  some  to  be  this, — that 
the  primary  will  have  a  more  distinct  action  upon  one  set  of  nerves,  and  the  secondary 
upon  another.  But  the  most  marked  physiological  difference  that  can  be  made  out  be- 
tween them  is  that  the  secondary  is  of  greater  intensity  than  the  primary,  and  will  some- 
times proceed  more  deeply  into  the  parts  you  wish  to  affect.  It  is  an  unhappy  use  of  the 
word  "primary,"  for  the  current  so  named  is  not  a  primary  current  in  the  sense  of  being 
a  battery  current ;  it  is  essentially  an  induced  current.  The  other  is  an  induction  from 
an  induction,  and  is  "  secondarily  "  induced,  and  the  clinical  difference  between  them  is 
mainly  one  of  intensity.  If,  then,  you  apply  the  terms  "  primary  "  and  "  secondary  "  to 
faradization  currents,  remember  that  you  should  mean  by  each  of  them  "  induced." 

[There  are  three  elements  to  consider  when  speaking  of  the  modification  of  electric 
sensibility — namely,  the  skin,  the  muscles,  and  the  nerve  trunks.] 

I.  In  health,  the  application  of  electricity  to  the  skin  is  accompanied  by  sensation 
varying,  in  kind  and  degree,  in  relation  to  the  form  and  the  force  of  the  agent  employed. 
Franklinic  electricity,  when  used  in  the  form  of  sparks,  produces  a  stinging  sensation  in 
the  skin,  M'hich  is  painful  to  some  people,  but  not  altogether  unpleasant  to  others.  The 
continuous  galvanic  current  produces  two  sensations  :  one,  a  feeling  of  burning,  which  is 
intense  in  proportion  to  the  force  that  is  employed,  and  which  is  especially  felt  at  the 
point  of  contact  of  the  positive  pole ;  the  other,  a  sense  of  tension  and  thrill  between 
the  poles.  Faradization  gives  rise  to  a  feeling  of  stinging  or  burning,  in  proportion  to 
the  intensity  of  the  induction,  the  rapidity  of  the  interruption,  and  the  dryness  of  the 
conductors. 

In  disease  the  electric  reactions  of  the  skin  may  be  much  changed.  The  patient  may 
exhibit  an  increase,  a  diminution,  or  an  entire  absence  of  sensibility. 

(a)  Increase  of  sensitiveness  is  found  in  many  simply  "  nervous  "  people,  whose  sen- 
sations are  all,  more  or  less,  exaggerated.  In  them,  too,  you  may  observe  much  of  the 
hysterical  character,  and  sometimes  it  is  obvious  that  the  increase  of  sensibility  is  due  to 
a  central — i.  e.,  to  a  mental  and  moral — state,  rather  to  any  peripheral  change.  But 
occasionally  you  find  that  the  skin  of  one  limb  is  more  sensitive  than  that  of  its  fellow, 


560  PSYCHOLOGICAL   MEDICINE. 

and  usually  that  this  increase  is  associated  with  augmented  sensibility  of  the  muscles  to 
electric  action.  The  diagnostic  value  of  this  change  is  identical  with  that  of  increased 
electric  contractility,  so  far  as  the  nature  of  the  lesion  is  concerned,  but  it  may  differ  from 
it  in  regard  of  the  precise  locality  of  change. 

{b)  Diminution  of  cutaneous  sensibility  to  electricity  is  met  with  when  there  is  the 
condition  of  "  shock"  which  accompanies  recent  and  suddenly  induced  paralysis;  and 
at  the  same  time  there  is,  commonly,  loss  of  tactile  sense  and  of  the  power  of  appre- 
ciating cold  and  heat.  It  is  also  found  in  some  cases  of  hysteria,  apart  from  any  paralysis 
or  other  change  of  motility;  and  it  may  exist,  as  a  chronic  symptom,  in  some  very  rare 
cases  of  central  disease. 

2.  When  the  muscles  are  put  into  action  by  electricity  the  healthy  individual  feels  their 
contraction.  If  the  force  employed  be  of  low  tension,  and  only  slowly  interrupted,  the 
sensation  is  not  unpleasant ;  but  if  the  current  be  of  high  tension,  or  be  very  rapidly 
made  and  broken,  the  feeling  in  the  muscles  amounts  to  pain,  and,  indeed,  to  very  severe 
pain,  of  cramp-like  character.  In  health  the  amount  of  sensation  is  in  direct  proportion 
to  the  force  of  the  contraction;  but  in  disease  this  relation  does  not  always  persist;  and, 
moreover,  there  are  certain  states  of  the  nervous  system  in  which  both  contraction  and 
sensation  are  together  morbidly  exaggerated  or  depressed. 

(«)  Increased  electro-muscular  sensibility  sometimes  exists  alone.  I  have  found  it  in 
the  trunk,  or  in  all  the  limbs,  or  in  only  one  of  them,  apart  from  any  general  or  local 
increase  of  contractility.  Patients  sometimes  feel,  and  feel  painfully,  an  amount  of  mus- 
cular contraction  which  they  would  scarcely  recognize  in  health;  and  this  painfulness  of 
muscular  movement  may  be  either  general  or  local.  It  is  usually  dependent  on  change 
in  the  central  nervous  system,  is  accompanied  by  increased  cutaneous  sensibility,  often  by 
neuralgia,  and  by  other  modifications  of  sensation — pseudsesthesia,  or  dyssesthesia — which 
are  sometimes  erroneously  termed  hypersesthesia. 

The  electro-muscular  sensibility  may  be  augmented,  pari  pnssti  with  the  increase  of 
contractility.  In  such  circumstances  the  muscles  act  more  energetically,  and  the  patient 
feels  that  action  more  acutely  than  he  should  do  in  health.  Sometimes  this  condition 
is  general,  and  then  the  only  comparison  that  can  be  made  is  between  the  patient  and 
the  average  of  other  men.  But  when  the  increase  is  local,  as  indeed  it  often  is,  the  limbs 
of  one  side  may  be  contrasted  with  those  of  the  other.  The  diagnostic  value  of  such 
increase  is  the  same  in  kind  as  that  which  I  have  already  described  to  you  when  speak- 
ing of  augmented  contractility. 

{b)  The  sensibility  of  the  muscles  is  usually  diminished  when  their  contractility  is  re- 
duced ;  and  this  diminution  is  commonly  in  direct  proportion  to  that  reduction — as,  for 
example,  in  lead-paralysis.  But  sometimes  there  is  other  than  this  parallel  deviation  of 
the  two  functions  from  their  healthy  standard.  We  meet  with  cases  in  which  the  con- 
tractility persists,  but  in  which  the  sensibility  is  diminished  or  extinguished.  The  muscles 
act  well,  but  the  patient  does  not  feel  their  action.  This  peculiar  relationship  is  observed 
in  some  cases  of  hysterical  paralysis,  but  I  have  also  found  it  in  individuals  who  had  ex- 
hibited none  of  the  ordinary  features  of  hysteria.  On  the  other  hand,  it  has  been  found 
that  in  rare  cases  of  lead-poisoning  the  sensibility  has  remained  intact  when  the  contrac, 
tility  has  been  diminished.  When  contractility  as  well  as  muscular  and  cutaneous  sen- 
sibility are  all  diminished  in  a  limb,  or  in  one-half  of  the  body,  the  condition  is  one 
either  of  "shock,"  or  of  extensive  cerebro-spinal  lesion;  the  time  during  which  the 
symptoms  have  lasted,  and  the  mode  of  their  onset,  will  enable  you  to  diagnosticate  be- 
tween them. 

3.  The  nerve  trunks  appear  to  be  so  involved  in  certain  electric  applications  that  sun- 
dry sensations  arise  from  their  irritation.     When  the  poles  of  a  galvanic  battery  are  ap- 


ELECTRICITY   IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  56 1 

plied  to  the  skin  in  close  proximity  to  one  another  the  nerve-trunks  may  escape ;  but 
when  they  are  widely  separated  some  nerve-trunks  maybe  involved  in  the  circuit;  and 
then,  with  the  continuous  current,  there  is,  in  proportion  to  its  strength,  a  feeling  of  ex- 
treme discomfort — of  straining  and  burning — between  the  poles,  and  some  sensation  of 
tingling,  numbness,  or  "  pins-and-needles,"  beyond  their  points  of  contact.  If,  under 
such  circumstances,  the  current  be  made  and  broken,  there  is  a  painful  feeling  of  shock 
at  or  about  the  joints  which  may  be  traversed.  A  similarly  painful  affection  of  the  nerve- 
trunks  may  be  observed  when  the  conductors  of  faradization  are  widely  separated.  But 
the  most  painful  of  all  modes  of  electrification  is  that  by  the  Leyden  phial,  the  sudden 
jar  which  is  given  by  this  mode  of  appliance  being  such  as  few  can  bring  their  minds  to 
bear,  A  strong  shock  from  a  large  Leyden  phial,  or  from  a  battery  of  phials,  will  some- 
times completely  paralyze  nerves  of  both  sensation  and  motion  in  the  parts  through  which 
it  has  passed. 

The  application  of  electricity  to  the  nerves  of  special  sense  produces  sensations  of 
special  kinds,  such  as  flashes  of  light,  a  phosphoric  odor,  a  saline  and  metallic  taste,  or  a 
rumbling  noise ;  and  these  sensations  may  be  induced  either  directly  or  indirectly.  Gid- 
diness, faintness,  or  nausea  may  be  also  brought  about  by  electricity;  but  the  clinical  uses 
of  such  applications  have  yet  to  be  discovered. 

In  some  cases  of  general  torpor  from  cerebral  disease  or  blood-poisoning,  and  in  de- 
structive diseases  of  the  spinal  cord,  and  in  these  alone,  do  we  find  the  diminution  of 
electric  sensibility  in  the  nerve-trunks,  when  that  function  is  appealed  to  in  the  manner 
that  I  have  described. 

Therapeutical  Uses  of  Electricity. — I  told  you  in  the  first  lecture  that,  by  the  aid  of 
electricity  you  might,  in  some  instances,  cure  a  case — e.  g.,  one  of  hysterical  aphonia ;  that 
in  other  cases  you  might  relieve  the  patient — of  pain,  spasm,  and  paralysis;  and  that,  in 
some  other  cases,  although  you  could  neither  cure  the  disease  nor  actually  diminish  the 
symptoms,  you  might  prevent  their  further  progress — you  might  arrest  the  disease. 

I.  Remembering  the  objects  that  we  have  in  view,  let  me  recall  to  you  for  a  moment 
what  it  is  that  electricity  can  do,  in  its  several  forms,  in  order  that  you  may  understand 
the  better  how  to  apply  it  to  the  various  conditions  of  disease. 

First,  it  may  call  into  action,  or  it  may  increase  the  action,  of  a  nerve  or  a  muscle  ;  and 
this  is  what  you  want  it  to  do  when  nerve  or  muscle  is  in  a  state  of  inaction  or  under- 
action. 

Secondly,  electricity  may  reduce,  or  even  annihilate  for  a  time,  the  action  of  a  nerve 
or  muscle ;  and  this  it  is  that  you  may  sometimes  want  to  accomplish  when  a  nerve  or 
muscle  IS  over-active.  You  can,  therefore,  use  it,  on  the  one  hand,  to  reduce  action  or  to 
stop  action,  when  this  is  excessive,  or,  on  the  other,  to  bring  out  the  action  of  a  dormant 
muscle  or  a  dormant  nerve.  If  you  have  paralysis,  loss  of  sensation,  or  loss  of  contrac- 
tility in  a  muscle,  you  may,  in  many  cases,  so  use  electricity  as  to  restore  voluntary  move- 
ment, to  restore  contractility,  to  restore  sensation.  If  you  have  pain,  over-action,  or 
spasm — whether  tonic  or  clonic — you  may  so  use  electricity  as  to  diminish  those  condi- 
tions, and  bring  nerve  and  muscle  to  their  normal  states.  The  mode  in  which  you  use 
electricity  will  determine  the  effect  that  you  produce. 

[a)  The  under-action  of  a  muscle  or  nerve  shows  itself  in  either  paralysis — using  that 
term  in  its  widest  and  most  general  sense — or  in  anaesthesia ;  or,  in  diminished  sensation 
— "  hypersesthesia,"  as  it  is  sometimes  called.  It  shows  itself,  also,  in  weakness  of  a 
limb;  there  need  not  be  what  we  call  "paralysis,"  but  the  limb  on  one  side  is  weaker 
than  on  the  other,  although  it  is  still  under  the  influence  of  the  will ;  by  a  strong  eff"ort 
the  patient  may  do  something  with  it — may,  indeed,  put  all  its  muscles  into  play,  but  the  ■ 
movements  are  slowly  produced,  and  are  wanting  in  force.     Still  further,  this  condition 

36 


562  rSYCHOLOGICAL    MEDICINE. 

of  under-action  shows  itself  in  a  relative  softness  of  nnuscle,  and  a  flabbiness  of  limb; 
although,  if  you  take  a  tape  and  carefully  measure  it,  you  will  find  it  of  the  same  size  as 
its  fellow.  You  can  feel  a  great  difference,  which  you  cannot  always  represent  by  figures ; 
but  often  there  is,  as  the  expression  of  central  disease,  actual,  obvious,  and  measurable 
wasting  of  muscles  and  of  the  other  tissues  of  the  limbs. 

(3)  The  over-action,  or  perverted  action,  of  a  nerve  or  muscle  shows  itself  by  spasm, 
as  contrasted  with  paralysis ;  by  hj-perassthesia,  as  contrasted  with  anjesthesia ;  or,  by 
spontaneous  pain,  or  something  which  is  not  spontaneous  pain,  or  genuine  hypersesthesia, 
but  which  has  been  called  "  dyssesthesia" — viz.,  a  painfulness  of  those  sensations  which 
are  habitually  unfelt  when  produced  by  ordinary  impressions.  For  instance,  when  there 
is  "  intolerance  of  light,"  it  is  not  that  the  patient  can  see  better  than  you  or  I ;  he  cannot 
see  nearly  so  well ;  but  he  suffers  pain  during  the  ordinary  act  of  vision.  Do  not  con- 
found this  with  genuine  hj^ersesthesia.  The  latter  is  rare,  the  former  comparatively 
common ;  but  both  may  be  sometimes  relieved  by  electricity. 

There  are,  further,  two  conditions  of  the  muscles  which  are  the  opposites  of  those  I 
mentioned  just  now — viz.,  first,  hardness  of  a  limb,  where  it  does  not  amount  to  actual 
rigidity ;  and  second,  actual  rigidity,  in  which  it  is  difficult  to  flex  or  extend  the  arm  or 
leg.  Further,  there  is  a  tremulousness  of  a  muscle ;  and  lastly,  clonic  spasm,  showing 
itself  in  slight  fibrillar  twitching,  or  in  catching  movements  of  the  limbs.  These  are  all 
signs  of  an  over-action  that  may  sometimes  be  reduced  by  electricity. 

As  part  of  its  effect  upon  muscular  fibre,  you  must  regard  also  the  action  of  electricity 
upon  the  vessels.  The  effect  on  vessels  is  simply  an  extension  into  another  region  of 
that  which  I  have  already  told  you  occurs  in  voluntary  muscular  tissue.  There  are  cer- 
tain contractile  fibres  in  the  walls  of  the  vessels,  and  j'ou  can  influence  them  by  electricity 
in  the  same  way  as  you  can  other  muscular  fibres.  If  the  vessels  are  dilated,  as  they 
ver)'  often  are  in  paralyzed  limbs,  you  find  that  the  skin  has  a  dusky,  bluish-red  tint,  and 
that  the  limb  is  cold.  Look  at  the  hands  of  a  semi-paralyzed  patient;  you  find  the  nails 
a  bluish-red,  the  extremities  cold,  and  the  capillary  vessels  large.  No  part  of  the  hand 
is  actually  white,  all  is  dusky  pink.  Here  electricity  is  useful ;  it  contracts  the  dilated 
vessels,  and  induces  a  healthy  state  of  the  circulation  in  the  limb,  which  no  other  means 
will  produce  so  readily.  You  can  do  this,  as  I  have  seen  again  and  again,  without  any 
electrification  of  the  voluntary  muscles.  If  you  act  on  the  muscles  of  the  limb,  and  draw 
the  hand  first  one  way  and  then  another,  you  gradually  increase  the  circulation  ;  but,  with- 
out calling  forth  the  action  of  any  of  these  muscles,  you  can  restore  or  much  improve 
the  circulation  in  the  skin  by  a  simple  superficial  electrification. 

It  is  possible  that  electricity  might  have  some  effect  upon  another  condition  of  blood- 
supply,  just  the  opposite  to  the  last — viz.,  that  in  which  the  vessel  is  contracted  by  the 
spasm  of  its  contractile  fibre.  I  do  not  know  that  here  electricity  has  been  of  any  prac- 
tical ser\'ice;  but  it  is  possible  that,  under  some  circumstances,  it  might  be  of  use.  At 
the  commencement  of  an  epileptic  seizure,  there  is  often  a  curious  pallor  of  the  face,  and 
to  a  condition  analogous  to  this  in  the  pia  mater  it  is  probable  that  the  loss  of  conscious- 
ness is  due.  It  is  possible  that  if  one  could  catch  a  patient  going  off  into  a  fit,  one  might 
stop  or  check  the  paroxj'sm.  In  those  persons  who  are  subject  to  sudden  pallors  coming 
over  the  face,  it  is  possible  that  by  a  due  administration  of  electricity  something  might 
be  done.  I  know  of  no  reliable  clinical  facts  about  the  electric  treatment  of  this  state 
of  spasm ;  but  in  the  other  condition,  in  which  you  get  engorged  vessels  from  loss  of 
contractility  of  the  fibre,  electricity  has  been  very  useful. 

2.  And  now,  what  are  the  modes  of  using  electricity  for  therapeutical  purposes? 
Over-activity  of  a  muscle,  or  nerve,  or  vessel,  may  be  reduced  by  the  application  of  the 
continuous  galvanic  current,  direct  in  its  course  through  the  limb,  passing,  that  is  to  say, 


ELECTRICITY    IN    DISEASES    OF   THE   NERVOUS    SYSTEM.  563 

downwards  and  not  upwards.  And  remember,  that  this  continuous  current  should  not 
be  so  strong  as  to  cause  pain;  it  should  be  applied  so  as  not  to  irritate  the  skin,  and  it 
should  be  applied  in  the  course  of  the  nerve,  from  above  downwards. 

Another  form  of  electricity — faradization — may  also  be  employed  to  reduce  over- 
activity. If  you  find,  for  example,  a  man  suffering  from  torticollis, — spasmodic  wry- 
neck,— the  sterno-cleido-mastoid  and  other  muscles  of  one  side  acting  most  violently, 
and  turning  the  head  over  to  the  opposite  shoulder,  you  may  stop  that  bypassing  through 
the  sterno-cleido-mastoid  muscle  a  galvanic  current,  or  by  applying  weak  faradization, 
rapidly  interrupted.  The  interruptions  have  to  be  very  rapid,  for  if  they  are  not  so  the 
application  only  increases  the  muscular  action.  The  interruption  in  a  rotary  magneto- 
electric  machine  is  scarcely  rapid  enough,  and  is  often  very  irregular;  one  of  Stohrer's 
batteries  may  be  used.  Remember,  then,  that  the  over-action  of  a  muscle  may  be  reduced 
by  the  application  of  faradization,  as  well  as  by  the  continuous  current,  but  that  the  fara- 
dization must  be  weak  and  rapidly  interrupted.  Another  way  by  which  you  may  reduce 
the  over-action  of  a  muscle,  is  by  faradizing  the  antagonist  muscle.  Supposing  the  flexors 
of  the  arm  are  contracted,  as  in  some  cases  of  "  late  rigidity,"  and  you  find  it  difficult  to 
get  the  fingers  open,  the  best  mode  of  overcoming  that  condition  is  to  apply  faradization, 
not  to  the  muscles  affected,  but  to  the  other  muscles,  the  extensors,  so  as  to  antagonize 
them.  Again,  in  the  case  of  torticollis,  where  a  man's  head  goes  jolting  over  to  one  side, 
you  can  reduce  the  over-action  by  putting  the  antagonistic  muscles  into  action  by  fara- 
dization, and  so  pulling  the  head  round  into  its  proper  position. 

By  the  third  form  of  electricity,  also, — static  or  Franklinic  electricity, — you  may  reduce 
over-action.  For  instance,  in  some  forms  of  tonic  spasm  and  painful  affections  of  nerves, 
you  may  reduce  the  over-action  by  charging  the  patient  from  a  friction  machine.  Thus, 
those  over-sensitive  conditions  of  nerves,  which  go  by  the  name  of  neuralgia,  may,  many 
of  them,  be  at  once  removed  by  a  charge  of  static  electricity,  and  in  the  same  manner 
the  electric  charge  may  be  employed  for  the  reduction  of  clonic  spasm,  or  of  that  tremu- 
lous condition  which  resembles  or  passes  into  the  state  of  paralysis  agitans. 

"When  either  a  nerve  or  a  muscle  exhibits  diminished  activity,  you  may  often  recall  its 
functions  to  their  proper  standard  by  the  use  of  electricity,  and  for  this  purpose  either  of 
the  three  forms  of  application  may  be  employed.  Franklinic  electricity  is  distinctly  useful 
in  some  cases  where  faradization  may  have  failed,  but  the  interrupted  galvanic  current 
and  faradization  are  those  which  are  most  commonly  applied. 

In  passing  from  these  generalities  to  details  of  electric  treatment,  I  will  first  speak  of 
cerebral  and  then  of  spinal  lesions. 

3.  First,  let  me  direct  your  attention  to  those  cerebral  diseases  which  cause  paralysis, 
and,  at  the  outset,  request  you  to  be  cautious.  If,  under  any  circumstances,  paralysis, 
induced  by  cerebral  disease,  occurs  suddenly,  you  should  not  use  electricity  at  all — at 
any  rate  as  a  therapeutic  agent — until  some  little  time  has  elapsed.  If  you  want  to 
examine  the  limb,  now  and  then,  for  the  purpose  of  diagnosis  or  prognosis,  you  may  use 
it  very  cautiously  with  a  low  power — e.g.,  a  Cruikshank's  battery,  or  some  other  form 
of  galvanism.  It  is  better  to  avoid  faradization  altogether,  for  you  may  set  up  mischief, 
or,  if  you  do  not  set  it  up,  some  mischief  may  occur,  and  you  may  get  the  credit  or  dis- 
credit of  having  caused  it.  Remember  that  the  discredit  may  be  entirely  due  to  you  for 
having  used  electricity  indiscriminately.  When  there  is  any  sudden  paralysis,  from  any 
cause, — whether  haemorrhage  into  the  brain,  or  some  embolic  blocking  up  of  a  vessel, 
or  some  sudden  congestion, — it  is  very  unwise  to  disturb  the  patient  in  any  way;  the 
best  thing  for  him  is  to  be  left  alone,  so  pray  do  not  use  electricity. 

But  when  the  onset  of  paralysis,  due  to  cerebral  lesion,  is  not  sudden,  there  is  one 
condition  under  which  I  should  advise  you  to  be  very  cautious  how  you  use  electricity, 


564  PSYCHOLOGICAL   MEDICINE. 

and  that  is  when  such  paralysis  is  attended  by  pain  in  the  head,  weight  of  head,  or  giddi- 
ness of  head.  When  these  symptoms  are  present,  it  is  well  to  postpone,  at  any  rate  for 
a  time,  electric  treatment,  and  this  although  the  symptoms  have  come  on  gradually.  But 
supposing  that  the  paralysis  has  come  on  slowly,  and  is  unattended  by  any  pain  in  the 
head,  or  by  any  of  the  other  symptoms  I  have  mentioned,  you  may  use  it,  and  that  fear- 
lessly ;  but,  at  the  same  time,  you  must  be  cautious  in  your  mode  of  applying  it,  for, 
although  you  may  be  fearless  about  it,  patients  sometimes  may  not  be  so,  and  it  is  very 
desirable  not  to  throw  electricity  into  disrepute  by  so  frightening  a  patient  with  your 
apparatus,  or  your  mode  of  using  it,  that  you  get  the  consequences  of  fright  set  down  to 
the  bad  effects  of  electricity.  I  have  known  this  to  occur  in  several  instances.  Young 
children,  and  even  some  who  in  other  matters  are  not  children,  have  sometimes  been  so 
frightened  by  the  look  of  an  electric  machine  that  serious  mischief  has  been  done  by  the 
fright,  mischief  which  the  electricity  used  oould  not  possibly  have  produced,  and  which 
has  sometimes  been  set  up  when  the  machine  has  not  been  used  at  all. 

I  pass  on  now  to  the  consideration  of  those  cases  in  which  you  may  be  recommended 
to  use  electricity  therapeutically,  and  here  must  redirect  your  attention  to  their  varying 
conditions. 

(a)  First,  let  us  consider  that  condition  in  which  the  contractility  of  the  paralyzed 
limb,  when  you  first  apply  the  electricity,  is  good  (testing  the  contractility,  of  course, 
according  to  the  mode  I  spoke  of  in  the  last  lecture).  On  applying  the  current,  you  find 
a  fair  amount  of  readiness  in  the  response  of  the  muscles.  The  patient  feels  the  elec- 
tricity, and  you  can  see  the  muscles  act.  It  need  not  move  as  strongly  as  the  healthy 
limb,  but  it  moves,  and  you  can  see  that  it  does.  There  may  or  there  may  not  be  any 
rigidity  of  muscles  under  these  circumstances,  but,  in  either  case,  you  do  little  or  no  good 
by  electricity.  You  may  diminish  the  rigidity,  you  may  improve  the  condition  of  the 
muscle,  it  may  become  firmer,  the  limb  may  become  a  little  warmer,  the  color  may  be 
more  natural,  that  dusky  blue  tint  that  you  so  often  find  may  be  removed ;  but,  so  far  as 
the  paralysis  is  concerned,  you  may  go  on  electrifying  the  patient  day  after  day  for  a 
twelvemonth,  and  at  the  end  of  that  time  find  him  as  much  paralyzed  as  he  was  at  the 
beginning.  That  is  my  experience,  and  it  is  so  with  regard  to  each  form  of  electricity. 
It  is  true  also  whether  the  paralysis  of  the  limb  be  complete  or  incomplete.  In  direct 
proportion  to  the  amount  of  contractility  present  is  the  uselessness  of  electricity.  If  the 
contractility  be  perfect,  although  the  paralysis  to  the  will  be  absolute,  you  can  do  nothing. 
If  the  contractility  be  retained,  and  be  only  very  slightly  diminished,  you  will  very  slightly 
improve  the  condition  of  the  limb,  and  very  slightly  improve  its  relationship  to  the  will. 

[d)  When  the  contractility  is  much  diminished,  there  is  much  good  that  you  may  do, 
and  you  will  be  able  to  do  it  by  working  upon  this  plan.  Use  electricity — in  such  a  form 
as  you  will  select,  on  the  principle  I  shall  mention  in  a  moment — till  you  bring  the  con- 
tractility of  the  limb  up  to  the  normal  standard,  and,  when  you  have  done  so,  stop.  Ycu 
will  usually  find  that  the  paralysis  is  diminished,  and,  in  some  cases,  that  it  is  cured. 
Let  me  remind  you  that  it  is  the  contractility,  and  not  the  power,  of  the  muscle  which  is 
to  be  your  guide,  and  assure  you  that  to  continue  electric  applications  when  the  contrac- 
tility is  normal  is  to  waste  your  own  time,  disappoint  your  patient's  hopes,  and  bring  elec- 
tricity into  disrepute. 

There  are  two  principal  modes  in  which  you  may  recall  the  lost  contractility,  viz. : 
the  application  of  the  battery  current,  and  the  application  of  faradization  ;  either  of  these 
will  be  of  service,  and  you  may  be  guided  in  your  choice  between  them  by  considera- 
tions of  convenience.  But  supposing  that  you  use  the  battery  current,  it  must  be  inter- 
rupted.    The  continuous  current  for  this  purpose  is  of  little  or  no  avail. 

Supposing  that  you  want  to  apply  galvanism  to  the  arm  or  the  leg  in  an  ordinary  case 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  565 

of  hemiplegia,  where  you  find  the  irritability  less  than  in  health.  The  best  way  to  ap- 
ply the  electricity  is  to  take  big  sponges  attached  to  handles  ;  not  little  sponges,  such  as 
are  applied  with  some  machines,  the  size  of  the  tip  of  the  little  finger,  but  good-sized 
sponges,  as  large  as  three  fingers,  a  good  inch  in  diameter.  The  handles  should  be  of 
such  a  shape  that  you  can  take  two  of  them  in  one  hand,  which,  for  certain  purposes,  is 
very  convenient.  Supposing  it  to  be  the  arm  that  you  wish  to  apply  it  to,  take  one 
sponge,  well  wetted,  and  put  it  on  the  shoulder,  over  part  of  the  deltoid  muscle,  with  the 
left  hand,  and  take  the  other  in  your  right,  also  well  wetted,  and  stroke  it  down  the  arm 
over  the  lower  part  of  the  deltoid,  then  down  the  back  over  the  triceps  muscle,  and  then 
over  the  biceps  in  front,  still  keeping  your  left  hand  upon  the  deltoid.  You  need  not 
spend  much  time  over  this;  a  few  brushings  down,  occupying  a  few  seconds,  are  enough 
for  the  arm  muscles.  For  the  forearm,  bring  the  upper  sponge  down  to  the  hollow  in 
front  of  the  elbow,  and  then  give  a  separate  stroke  to  the  muscles  here  and  there  over 
the  forearm.  In  the  early  days  of  a  case  of  paralysis  of  the  upper  extremity  depending 
on  cerebral  causes,  I  should  not  advise  you  to  waste  time,- as  you  would  be  doing  in  de- 
voting much  attention  to  the  small  muscles  of  the  hand.  You  may  simply  take  a  sponge 
and  bring  it  down  the  fingers.  In  the  lower  limb  you  may  in  the  same  manner  take  one 
sponge  and  place  it  on  the  gluteal  region,  and  with  the  other  work  down  the  limb. 
What  you  are  doing  is  this  :  you  are  constantly  making  and  breaking  the  battery-current 
through  the  limb  by  moving  the  sponge  slowly  downwards.  If  you  were  to  leave  it  in 
one  spot,  it  would  be  a  constantly  continuous  current  through  the  limb.  By  moving  it 
you,  at  the  same  time,  bring  the  current  through  every  point  of  the  muscles,  so  as  to  em- 
brace each,  from  one  end  to  the  other,  in  an  mterrupted  battery-current ;  and  that  is  what 
you  want  to  do  to  waken  up  its  sensitiveness  and  contractility. 

Respecting  the  use  of  electricity  in  this  form,  you  will  sometimes  see  statements  made 
about  the  use  of  the  inverse  current  in  one  case,  the  direct  in  another.  I  have  never 
seen  the  slightest  difference  between  the  two,  in  their  therapeutical  effect  upon  paralysis, 
and  I  have  compared  them  again  and  again.  If  the  currents  act  continuously,  the  phys- 
iological effect  on  the  nerve  does  differ  in  the  two  cases,  the  current  downwards  diminish- 
ing the  irritability,  the  current  upwards  increasing  it ;  but  the  therapeutical  effects  of  the 
direct  and  inverse  currents,  applied  as  I  have  described,  do  not  differ.  In  speaking  of 
this,  let  me  remind  you  of  another  fact  which  I  alluded  to  in  the  first  lecture,  viz.,  that 
the  current  in  passing  down  a  limb  acts  more  strongly  than  it  does  in  passing  up  it. 
Supposing  we  had  a  Cruikshank's  battery  here  of  five  cells,  and  that  five  cells  was  the 
minimum  power  that  would  induce  contraction  in  a  limb  when  the  current  was  passing 
down  the  limb;  you  will  find  that  the  current  from  the  five  cells,  if  sent  up  the  limb, 
will  not  produce  contraction.  So  you  must  remember  this  fact  in  relation  to  the  strength 
of  the  current. 

So  much,  then,  for  the  mode  of  application  of  the  battery-current;  a  large  sponge 
well  wetted  with  salt  and  water ;  the  upper  sponge  kept  pretty  steady,  the  other  one 
moved  slowly  down  the  limb  along  the  course  of  the  muscles  so  as  to  embrace  different 
portions  of  muscles  in  the  current,  and  using  a  stronger  or  a  milder  current,  according 
to  the  direction  in  which  you  send  the  electricity.  But  which  ever  form  you  use,  please 
remember  that  you  are  to  use  such  a  force  as  is  not  painful ;  and  you  are  to  use  such  a 
force  as  will  produce  contraction.  So  just  stop  between  the  two  extremes ;  do  not  use 
so  weak  a  force  that  it  is  doing  nothing,  or  so  strong  a  force  as  shall  be  doing  harm.  The 
best  guide  for  you,  until  you  have  had  some  experience  of  the  individual  upon  whom 
you  are  going  to  apply  it,  is  to  try  it  on  your  own  hand  first;  place  it  on  your  own  hand, 
and  use  such  a  power  as  shall  just,  to  your  own  consciousness,  feebly  move  the  muscle. 
You  find  sometimes  that  you  are  more  sensitive  than  your  patient,  sometimes  that  he  is 


566  PSYCHOLOGICAL    MEDICINE. 

more  sensitive  than  you  ;  but  do  not  use  any  strength  that  hurts  you.  Whatever  hurts  a 
muscle,  so  far  as  the  sensation  of  the  patient  is  concerned,  positively  hurts  the  patient. 
Electricity  should  never  hurt  people  if  you  want  to  cure  or  relieve  paralysis.  •  Use  such 
a  power,  then,  as  shall  be  distinctly,  but  not  painfully,  felt.  I  think  that  too  great  im- 
portance can  scarcely  be  attached  to  this.  I  have  known  electricity  so  applied  to  a 
patient's  limbs  that  he  or  she  almost  fainted,  and  the  electricity  has  done  no  good.  Of 
course  not.  The  idea  of  applying  electricity  to  a  paralyzed  limb  so  as  to  put  the  mus- 
cles into  a  state  of  cramp !  That  is  the  most  mischievous  thing  you  can  do.  Instead  of 
waking  up  a  natural  action,  you  put  it  in  the  most  hurtful  form  of  action. 

Further,  do  not  prolong  the  application  until  the  muscles  or  the  patient  is  tired.  If 
you  wear  the  muscle  out,  you  do  it  as  much  harm  as  when  you  pain  it.  A  few  seconds 
devoted  to  each  muscle  are  quite  enough,  and  you  may  repeat  this  every  day,  or  you 
may  repeat  it  every  other  day,  according  to  the  sensitiveness  of  the  patient.  It  is  very 
much  better  to  repeat  it  even  twice  a  day,  where  arrangements  for  so  doing  can  be  con- 
veniently made,  than  to  continue  it  for  a  number  of  minutes  at  a  time,  and  so  distress  or 
weary  the  limb.  If  you  find  that  the  application  of  this  or  any  form  of  electricity  is  fol- 
lowed by  weariness  in  the  limb,  giddiness  in  the  head,  pain  in  the  head,  a  feeling  of 
faintness  or  of  sickiress,  a  nondescript  sense  of  discomfort  about  the  epigastrium,  do  not 
go  on  with  the  electricity  at  all;  cease  altogether  for  a  time. 

If  )'ou  are  about  to  use  faradization,  there  are  two  or  three  points  to  be  observed. 
You  are  not  to  tire  the  patient,  not  to  pain  the  patient ;  therefore  your  application  must 
be  brief,  and  your  current  of  moderate  tension.  You  are  to  apply  faradization  with  well- 
moistened  sponges,  or  buttons  covered  with  wet  chamois  leather ;  because,  otherwise, 
you  may  irritate  the  skin,  but  produce  no  further  action.  You  are  to  apply  the  current 
to  the  muscles  ;  but  there  is  a  difference  in  the  mode  of  application  of  the  faradic  and 
the  galvanic  current.  With  the  galvanic  current  you  may  place,  as  I  said,  one  sponge 
on  the  shoulder  and  the  other  on  the  palm  of  the  hand.  Do  not  do  that  with  faradiza- 
tion, but  keep  the  two  poles  near  together.  It  is  never  worth  while  and  never  advisable  to 
separate  them  widely.  It  is  a  good  rule  in  ninety-nine  cases  out  of  a  hundred,  to  hold 
both  in  one  hand.  There  is  a  double  reason  for  this ;  one  is,  that  you  cannot  then  get 
them  very  widely  separated  ;  the  other  is,  that  you  have  the  remaining  hand  at  liberty. 
If  you  separate  the  two  poles  of  a  faradic  apparatus  widely,  you  are  in  great  danger  of 
giving  the  patient  pain  without  doing  him  good,  and  upsetting  the  circulation  in  his 
head.  If  you  take  a  tolerably  strong  faradic  current  and  apply  it  to  the  palms  of  both 
hands,  you  will  find  very  uncomfortable  sensations  in  several  parts,  especially  in  the 
joints,  wrists  and  elbows  ;  and  if  you  look,  you  will  see  very  little  muscular  action  at  all. 
On  the  other  hand,  if  you  put  the  two  poles  near  together,  you  will  find  that  you  can  put 
the  muscles  of  the  limb  into  tolerably  strong  action  with  a  comparatively  weak  current, 
and  without  causing  any  pain. 

In  the  treatment  of  paralysis  it  is  important  for  you  to  bear  this  in  mind  :  Take  both 
poles  in  one  hand,  and  act  upon  all  the  muscles  seriatim.  Begin  with  the  deltoid,  first 
acting  on  the  anterior  set  of  fibres,  then  on  the  middle,  then  on  the  posterior;  go  down 
to  the  biceps  and  triceps,  and  then  faradize  the  upper  part  of  the  forearm.  In  the  first 
few  applications  you  need  not  go  beyond  the  arm  and  forearm ;  and  afterwards,  when 
these  are  in  a  better  state,  it  is  desirable  to  pay  special  attention  to  the  muscles  of  the 
hand.  In  these  you  want  handles  with  rounded  ends,  narrow  stems,  and  metallic  but- 
tons covered  with  chamois  leather.  Make  them  wet ;  take  the  two  in  one  of  your  hands, 
and  pick  out  the  different  muscles  of  the  patient's  hand  separately,  and  especially  the 
little  interosseous  muscles.  By  groping  about  you  will  gain  a  certain  amount  of  skill,  so 
as  to  be  able  to  pitch  quickly  on  the  particular  muscles  that  you  want  to  influence. 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS   SYSTEM.  56/ 

You  will  find  that,  in  both  arm  and  leg,  there  are  particular  points  at  which,  if  you 
apply  your  current,  you  will  put  the  muscles  into  much  stronger  action  than  if  you  apply 
it  elsewhere.  Generally  speaking,  these  points  are  where  the  nerves  entering  the  muscles 
are  most  superficial ;  knowledge  of  anatomy  will  help  you  find  these  points;  but  there  is 
sufficient  variation  from  these  to  make  it  necessary  for  you  to  examine  the  question  elec- 
trically, and  to  discover  for  yourself,  even  in  special  cases,  the  points  through  which  the 
current  may  be  sent  with  the  greatest  efficacy. 

Sometimes  you  will  find  curious  actions  which  you  cannot  very  readily  explain.  For 
example,  in  faradizing  the  perineal  muscles  and  the  tibialis  anticus,  by  applying  one  pole 
just  behind  the  head  of  the  fibula,  you  may,  by  placing  the  other  pole  above  the  knee, 
on  either  side,  raise  the  heel  from  off  the  ground  or  the  bed,  by  calling  the  psoas  and 
iliacus  muscles  into  action.  I  have  seen  the  foot  raised  from  eight  to  ten  inches  from  the 
floor  in  this  manner  by  a  patient  who  could  not  lift  the  heel  higher  than  two,  or  at  the 
most  three,  inches  by  the  extreme  of  voluntary  effort. 

Now,  what  do  you  do  when  you  apply  electricity  in  this  way  ?  You  may  restore,  if  it 
be  lost,  the  nutrition  of  the  muscles ;  you  bring  back  their  bulk.  If  the  limb  be  cool,  as 
it  very  often  is,  from  the  defective  circulation,  you  may  bring  back  the  normal  tempera- 
ture. When  the  contractility  has  been  defective,  you  bring  that  back  to  its  normal  state, 
and  you  will  find  then  that  you  have  very  much  improved  the  relationship  of  that  limb  to 
the  will  of  the  individual;  that  is,  yoM pro  tanto  improve,  or  it  may  be  entirely  cure,  the 
paralysis.  The  mode  in  which  electricity  produces  this  effect,  so  far  as  we  can  under- 
stand it,  is  this  :  A  limb  has  been  out  of  use  for  a  certain  time ;  its  muscles  and  nerves 
have  lost  their  nutrition  and  their  readiness  to  act;  and  the  application  of  electricity  has 
quickened  the  circulation  and  restored  the  diminished  function  of  those  tissues.  We  may, 
I  think,  go  still  further,  and  affirm  that,  in  some  instances,  much  more  is  accomplished 
than  this  merely  peripheral  effect.  By  stirring  up  the  muscles  and  nerves  of  a  limb,  you 
may,  to  a  certain  extent,  act  upon  the  other  ends  of  those  nerves, — the  ends  that  are  in 
the  back  or  head, — and  so  you  may  improve,  by  careful  usage,  the  nutrition  of  the  spinal 
cord,  or  of  the  brain.  There  can,  I  think,  be  no  doubt  of  the  reality  of  this  secondary 
result.  It  is  obvious  that  faradization  of  the  extremity  may  seriously  derange  the  circu- 
lation in  the  head;  and  it  is  no  less  clear  that  its  application  may  be  followed  by  results 
which  a  change  in  the  conditions  of  the  limb  will  not  explain. 

4.  There  is  another  point  to  which  I  will  call  your  attention,  and  that  is  the  condition 
of  "  rigidity  "  in  a  limb  in  cerebral  paralysis.  It  is  common  enough  in  old  cases,  and 
sometimes  is  met  with  in  those  that  are  quite  recent.  In  the  latter  cases  I  advise  you  not 
to  use  electricity,  for  you  may  do  harm ;  in  late  rigidity  you  may  employ  it  without  fear, 
and  with  considerable  advantage.  Here  you  may  either  remove  the  rigidity  altogether, 
and  also  improve  the  contractility  of  the  limb,  or  you  may  only  diminish  the  rigidity,  or 
prevent  its  increase.  It  often  happens  that,  in  a  case  of  three  or  four  months'  duration, 
you  find  the  flexor  muscles  beginning  to  contract,  so  that  the  patient,  waking  up  from 
sleep,  in  the  night  or  in  the  morning,  always  finds  his  fingers  bent,  and  the  forearm  prone, 
the  flexure  soon  passing  away  again  by  a  little  rubbing  or  passive  movement.  After  a 
time,  although  the  hand  may  still  be  opened,  it  shows  a  constant  tendency  to  close  when 
it  is  left  to  itself,  and  at  last  the  closure  gradually  becomes  habitual.  Now,  the  best  way 
to  counteract  this  tendency  to  closure  is  to  faradize  the  antagonist  muscles,  the  extensors 
of  the  fingers,  and  supinators  of  the  forearm.  Under  such  circumstances,  you  need  not 
begin  at  the  shoulder,  because  contraction  of  the  kind  I  have  been  speaking  of  always  be- 
gin at  the  distal  end.  You  do  not  notice  rigidity  of  the  elbow  till  some  time  after  you  have 
noticed  it  at  the  wrist,  nor  do  you  observe  rigidity  of  the  wrist  until  after  that  of  the  fingers 
has  been  conspicuous.  Sometimes  in  an  early  stage  a  few  applications  of  electricity  will  cure 


568  PSYCHOLOGICAL    MEDICINE. 

the  rigidil}',  and  not  only  remove  the  tendency  to  cramp,  but  even  bring  back  the  proper 
contractility  of  the  limb.  But  in  more  severe  and  protracted  cases,  in  which  there  is  some 
persistent,  and  often  progressive,  lesion  of  the  head,  you  cannot  cure  the  rigidity — i.  e., 
you  cannot  remove  it  altogether ;  but  even  in  these  cases  you  may  sometimes  do  good. 
You  may  prevent  it  from  getting  as  bad  as  it  would  do  if  left  alone,  and  this  is  a  very 
important  thing  to  do ;  for,  after  a  longer  time,  the  rigidity  becomes  extreme,  and  the 
patient  often  refuses  to  submit  to  any  treatment.  Then  it  is  found  that  the  nails  have 
dug  into  the  hand,  and  that  the  pent-up  perspiration  has  become  fetid  and  disgusting.  It 
is  impossible  to  prevent  the  occurrence  of  sores  in  some  cases,  except  by  a  timely  elec- 
trification of  the  extensors.  You  may  often  call  into  action  the  extensors  of  a  much 
weakened  hand  by  applying  a  moderate  faradization  with  well-wetted  sponges  to  the 
back  of  the  forearm,  or  you  may  use  galvanization  for  the  same  purpose,  interrupting  the 
current  in  the  manner  I  have  described,  viz.,  by  putting  one  sponge  on  the  back  of  the 
forearm  over  the  skin  well-wetted,  and  making  and  breaking  the  current  with  the  other 
hand  by  moving  the  sponge  upwards  and  downwards  an  inch  or  two  below  the  upper 
pole.  But  faradization  is  much  better  for  this  purpose  than  is  the  batteiy  current,  al- 
though the  latter  may  be  used  to  assist  the  former  by  applying  it,  in  a  continuous  form, 
to  the  rigid  and  overacting  muscles.  For  this  purpose  the  current  should  be  direct ;  one 
pole,  well-wetted,  should  be  placed  in  the  hollow  of  the  elbow,  and  the  other  in  the 
hand.  A  moderate  current  should  be  allowed  to  pass  continuously  from  the  upper  to  the 
lower  for  ten,  fifteen,  or  twenty  minutes,  once  or  twice  daily,  according  to  the  severity  of 
the  case.  You  faradize  the  extensors  and  galvanize  the  flexors  of  the  hand  and  fingers  ; 
and  you  may,  if  the  rigidity  has  extended  higher,  adopt  a  similar  plan  with  regard  to  the 
muscles  of  the  forearm  or  the  arm. 

5.  Shaking  movements  sometimes  occur  in  cerebral  diseases,  and  may  take  the  form 
of  mere  tremulousness,  or  of  clonic  spasm.  In  these  cases  relief  may  be  given  by  two 
forms  of  electricity.  It  may  be  given  by  static  electricity,  charging  the  patient  generally 
with  positive  electricity,  and  leaving  it  there,  having  previously  placed  him  on  a  glass- 
legged  stool.  Or  you  may  pass  a  continuous  current,  of  low  force,  through  a  tremulous 
limb.  In  this  case  the  best  way  of  applying  it  is  to  place  the  patient's  feet  in  a  pan  of 
salt  and  water,  to  put  the  pole  from  the  negative  end  of  the  battery  into  the  water,  and 
then  let  the  patient's  hand  be  placed  in  a  basin  of  salt  and  water,  connected  with  the 
other  pole.  The  current  will  then  come  up  the  leg  and  down  the  arm ;  and  you  will 
find  that  in  many  cases  of  tremor  or  clonic  spasm  accompanying  paralytic  conditions 
dependent  on  cerebral  disease,  this  continuous  current  affords  marked  relief. 

6.  It  will  be  well  to  consider  here  the  electrical  treatment  of  chorea.  Years  ago  it  was 
said  that  good  results  were  obtained,  but  I  must  say  that,  so  far  as  my  own  experience 
goes,  electricity  has  done  no  good  in  this  disease.  There  are  a  vast  number  of  cases  of 
acute  chorea  that  will  get  well  if  you  leave  them  alone,  and  almost  any  form  of  treatment 
will  appear  to  prove  efficacious  if  it  be  taken  in  conjunction  with  change  from  a  crowded 
dwelling-house  to  a  well-ventilated  hospital  ward,  fo  good  food  and  quiet.  I  believe  a 
great  deal  of  the  influence  set  down  to  electricity,  ice-bags,  iron,  arsenic,  quinine,  and 
other  medicine  has  been  imaginary,  and  that  the  really  curative  agents  have  been  those 
that  I  have  mentioned.  The  modes  employed  have  been  the  forms  of  electricity,  and 
each  one  has  lauded  in  the  treatment  of  chorea  that  particular  form  to  which  he  is 
addicted ;  but  in  my  judgment  the  less  one  says,  in  the  present  state  of  knowledge,  about 
chorea  and  its  treatment  by  electricity,  the  better  will  it  be  for  therapeutical  science. 

7.  I  pass  now  to  the  consideration  of  some  brain  affections  that  are  accompanied  by 
alterations  in  sensibility.  And,  first,  defective  sensation,  or  anaesthesia.  Ansesthesia  of 
a  limb,  or  of  two  limbs,  is  very  rare,  except  in  association  with  motor  paralysis,  and  then, 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS   SYSTEM.  569 

when  it  has  occurred  acutely,  it  usually  exists  only  during  the  condition  of  shock.  A 
patient,  for  instance,  may  become  hemiplegic  from- an  embolism,  or  from  hsemorrhage, 
and  you  will  find  that  during  the  first  few  minutes,  or  sometimes  few  hours,  or,  in  rarer 
cases,  days,  after  the  onset  of  the  attack,  there  may  be  soine  loss  of  sensibility.  It  varies 
in  amount,  but  during  the  condition  of  shock  may  be  occasionally  well  marked.  But 
after  that  condition  of  shock  has  passed  away,  the  sensibility  commonly  returns,  and,  so 
far  as  electricity  is  concerned,  all  I  have  to  say  is  that,  during  that  time,  it  would  be  very 
unwise  to  use  any  form  of  electricity  at  all. 

In  certain  brain  diseases  of  slow  development  you  may  find  loss  of  sensibility,  but 
these  are,  comparatively  speaking,  rare.  You  every  now  and  then  meet  with  some  por- 
tion of  skin  defective  in  sensibility,  from  a  tumor  in  the  head  or  some  other  cause.  But 
it  is  much  more  common  for  you  to  find  some  modified  sensibility,  such  as  "  pins-and- 
needles,"  or  painful  impressions  when  the  skin  is  touched.  In  those  cases  of  acute 
cerebral  disease,  however,  in  which  you  do  find  persistent  anesthesia,  or  even  only 
diminished  sensibility,  it  is  very  rare  for  you  to  find  that  electricity  does  any  good.  It 
may  do  harm,  and  I  should  advise  you  not  to  use  it  unless  the  case  were  of  such  sort 
that  you  used  it  only  for  the  purpose  of  diagnosis,  and  then  only  in  such  a  form  as  you 
feel  quite  sure  can  do  no  mischief. 

The  examples  of  anaesthesia  in  which  electricity  is  most  useful  are  to  be  found  in  that 
curious  class,  or  rather  medley,  of  cases  that  goes  sometimes  by  the  name  of  "  hysterical," 
for  they  are  met  with  in  women,  and  are  found  together  with  symptoms  of  the  kind 
commonly  regarded  as  hysterical.  Here  you  meet  with  marked  anaesthesia  of  the  skin 
in  different  parts  of  the  body,  almost  always  associated  with  a  certain  amount  of  awkward- 
ness of  movement,  and  sometimes  associated  with  some  very  definite  loss  of  power.  The 
two  often  go  together,  for  both  the  apparent  power  of  combining  movements  are  distinctly 
related  to  the  integrity  of  guiding  sensations  derived  from  impressions  made  upon  the 
skin.  I  have  known  cases  of  this  kind  which  had  lasted  for  months  or  years,  in  which 
movements  of  the  body  or  of  certain  limbs  were  weak  and  clumsy,  and  in  which  the 
patients,  finding  it  awkward  to  use  their  limbs,  had  ceased  to  do  so,  and  in  whom,  from 
disuse,  the  muscular  power  had  become  defective,  but  in  which  electricity  has  proved 
wonderfully  useful,  for  sometimes,  after  only  a  few  applications,  the  sensibility  and  mo- 
tility has  been  restored  completely.  Electricity  should  here  be  employed  in  such  a  manner 
as  to  produce  a  definite  and  distinct  impression  on  the  skin.  Supposing  there  is  anes- 
thesia of  the  skin  of  the  leg,  place  one  pole  of  a  faradic  apparatus  in  the  patient's  hand, 
attach  to  the  other  a  dry  metallic  brush,  and  pass  it  over  the  surface  of  the  skin.  In 
that  way  you  send  in  a  number  of  little  bright  sparks,  which  you  may  see  very  plainly 
in  the  dark,  and  you  sting  the  skin  very  briskly.  Or  you  may  take  a  charcoal  conductor, 
or  a  metallic  conductor,  and  move  it  up  and  down  on  the  surface  of  the  skin.  In  the 
first  few  moments,  perhaps,  the  patient  does  not  feel  it  at  all,  but  you  now  and  then  find 
the  sensibility  of  the  skin  return  with  marvellous  rapidity.  Sometimes  you  will  find  it 
is  a  better  plan  to  take  two  thoroughly  wetted  sponges  and  a  tolerably  strong  current  to 
make  the  muscles  act  briskly.  By  so  doing,  in  the  course  of  a  few  minutes  the  skin  will 
often  recover  its  sensibility.  I  am  not  able  to  explain  thoroughly  why  this  should  be, 
but  I  have  seen  it  again  and  again.  An  analogous  condition  is  that  in  which  the  skin 
retains  its  sensibility  while  the  muscles  have  lost  their  contractility,  and  in  which  by 
stinging  the  skin  you  will  sometimes  restore  the  muscular  contractility. 

Whatever  may  be  their  explanation,  these  are  facts,  and  they  have  a  certain  relation  to 
each  other.  In  facial  paralysis,  for  instance,  by  stimulating  the  skin,  either  by  electricity 
or  by  a  blister,  you  may  often  bring  back  the  muscular  action  very  speedily.  Or,  where 
there  is  a  loss  of  sensibility  of  the  skin,  the  muscles  acting  tolerably  well,  you  may,  by 


$yO  ■  PSYCHOLOGICAL    MEDICINE. 

putting  them  into  forced  action,  restore  the  sensibility  of  the  skin.  I  think  that  most 
likely  what  one  does  under  these  circumstances  is  to  stimulate  that  which  is  common  to 
both  muscle  and  skin,  viz.,  vessels ;  and,  further,  that,  in  thus  acting  on  the  skin,  we  exert 
some  influence  on  the  nerve-trunks,  and  also  on  their  central  extremities. 

You  may  accomplish  the  same  end  by  Franklinic  electricity,  by  directing  sparks  from 
a  prime  conductor  to  the  part  affected,  or  by  "  charging  "  the  patient,  and  taking  sparks 
away  from  the  surface  by  your  knuckle  or  a  brass  ball.  The  effect  of  this  application  is, 
that  in  a  little  time  you  redden  the  skin  and  restore  the  sensibility.  In  extreme  cases  you 
may  go  still  further  and  apply  a  moderate  charge  from  a  Leyden  phial.  For  instance, 
you  may  inclose  a  limb  between  the  knob  and  the  discharging  rod  and  let  the  shock  go 
through  it.     This  will  sometimes  bring  back  the  sensibility  when  other  means  have  failed. 

8.  There  are  two  classes  of  spinal  diseases  to  which  I  have  already  alluded,  in  one  of 
which  you  have  the  true  "  spinal  paralysis  "  of  Dr.  Marshall  Hall ;  in  the  other  of  which 
you  have  "cerebral  paralysis,''  although  depending  on  spinal  disease.  In  the  one  the 
muscle  derives  nothing  from  the  cord,  because  the  latter  is  diseased  or  destroyed;  in  the 
other  the  muscle  is  still  associated  with  the  cord,  though  that  cord  may  be  cut  off  from 
the  brain. 

(a)  First,  let  us  take  the  case  of  the  true  spinal  paralysis.  What  can  you  do  there 
electrically  ?  The  damage  done  to  the  cord  is  to  be  measured  by  the  loss  of  electric 
irritability,  and  this  whatever  may  be  the  form  of  electricity  that  you  employ.  If  the 
electric  irritability,  in  a  case  of  this  kind,  be  absolutely  gone,  and  show  no  sign  of  reap- 
pearance after  four  or  six  applications,  your  prognosis  is  bad,  and  there  is  little  or  nothing 
to  be  gained  by  a  persistence  in  the  treatment. 

Where  you  find  a  certain  amount  of  contractility  remaining,  there  is  a  great  deal  to  be 
done.  You  compare  the  limbs  of  your  patient  with  the  healthy  limbs  of  some  one  of  the 
same  age  and  sex,  same  class  of  constitution  and  thickness  of  skin,  and  if  you  find  con- 
tractility diminished  somewhat,  but  not  lost,  there  is  much  room  for  hope,  and  a  great 
deal  will  depend  upon  what  you  do  as  to  the  upshot  of  the  case  in  the  future. 

Take,  as  an  instance,  the  case  of  "  infantile  paralysis  "  (so-called  "  essential  paralysis  " 
of  children),  one  of  the  best  examples  you  can  have.  A  child  is  a  little  feverish  for 
twenty-four  hours ;  you  find  it  cannot  sit  up,  cannot  move  its  arms  or  legs  for  a  few  days. 
Then  it  begins  to  move  one  arm  a  little,  and  perhaps  one  leg ;  after  a  day  or  two  more 
perhaps  both  arms.  If  you  do  not  notice  it  again  for  a  week,  you  may  find  one  limb 
completely  paralyzed  and  the  other  partially,  the  distribution  varying.  Post-mortem 
examination  in  such  a  case  shows  very  often  disease  of  the  spinal  cord  itself,  running 
along  its  whole  length,  a  disease  which,  when  left  to  itself,  eventuates  in  the  destruction 
of  the  tissue  of  the  spinal  cord,  producing  in  the  first  instance  perfect  spinal  paralysis, 
and  in  the  last  instance  perfect  spinal  paralysis  also,  but  the  former  curable,  the  latter 
perfectly  incurable.  In  the  early  stage  you  find  a  certain  amount  of  contractility  left,  but 
that  is  very  defective.  Here  very  much  may  be  done  by  electricity.  You  find  also  this 
curious  point,  that  the  muscles  respond  much  more  readily  to  a  slowly  interrupted  current 
than  to  a  rapidly  interrupted  current.  To  faradization  you  will  find  them  defective,  and 
sometimes  you  cannot  get  them  to  act  at  all.  If  you  interrupt  the  battery  current  very 
rapidly,  they  sometimes  will  not  act  to  it,  but  if  you  interrupt  it  slowly,  you  find  that  they 
do.  And  what  is  very  interesting  about  these  cases,  and  to  which  I  have  already  alluded, 
is  this, — that  the  muscles  sometimes  appear  to  act  much  more  readily  than  those  in  health 
to  a  very  low  current  of  galvanization. 

To  such  cases  the  battery  current,  slowly  interrupted,  should  be  applied  with  a  wet 
sponge,  in  the  manner  I  described  the  other  day.  It  should  be  applied  every  day  for  a 
few  minutes,  not  troubling  yourselves,  at  first,  about  particular  groups  of  muscles,  but 


ELECTRICITY    IN    DISEASES    OF   THE   NERVOUS    SYSTEM.  5/1 

just  applying  it  to  the  whole  limb.  If  it  is  the  leg,  put  one  of  your  sponges  on  the  sa- 
crum, just  below  the  groin,  or  in  the  gluteal  region,  and  move  the  other  sponge  slowly 
down  the  front  of  the  thigh,  and  then  the  back  of  the  thigh  and  leg.  You  often  find, 
under  such  circumstances,  that  after  a  day  or  two  you  have  to  use  a  stronger  power  to 
produce  the  effect  that  you  produced  at  first;  and  you  will  find  at  the  same  time  that  the 
muscles  respond  more  readily  to  faradization.  It  is  well,  then,  to  change  and  employ 
faradization  instead,  using  it  with  sponges  well  wetted,  trying  to  pick  out  particularly 
certain  sets  of  muscles  which  have  a  trick,  as  it  were,  of  lagging  behind  the  others. 
These  are,  especially,  the  extensors  of  the  foot,  the  perinei,  and  the  extensors  of  the 
fingers.  Here,  then,  you  may  apply  faradization ;  and  if  the  disease  in  the  spinal  cord 
be  curable,  I  am  sure  you  assist  the  process  of  the  cure.  If  the  disease  has  existed 
for  some  time  before  the  case  is  brought  to  you, — and  cases  are  often  brought  after 
three  or  four  years'  duration, — you  will  still  find  that  occasionally  you  can  do  some- 
thing. You  may  call  into  exercise  the  muscles  of  the  limb;  you  can  improve  their 
nutrition  and  their  strength ;  and  you  may  do  something  towards  effecting  a  change  in 
the  nutrition  of  the  cord  itself.  Where,  however,  the  disease  has  existed  for  some 
time,  I  have  not  seen  that  the  repeated  use  of  electricity  has  done  much  good,  unless  the 
improvement  has  been  rapid  at  the  commencement  of  treatment.  You  may  see  some 
enlargement  of  muscles,  but  there  the  improvement  ends.  When  you  find  that,  after  four 
or  six  applications,  there  is  no  sign  of  electric  contractility  either  by  the  induced  or 
the  battery  current,  it  is  useless  to  go  on.  I  have  managed  every  now  and  then  to 
have  cases  treated  for  many  months,  with  the  forlorn  hope  that  at  some  period  or  another 
there  might  be  a  ghost  of  contractility  returning,  but  I  must  say  it  has  been  utterly  un- 
successful. 

(d)  Let  me  now  direct  your  attention  to  cases  of  paralysis,  dependent  upon  spinal  dis- 
ease, in  which  there  is  not  any  true  "  spinal  paralysis"  ;  for  the  muscles  still  retain  their 
connection  with  a  healthy  portion  of  the  medulla,  although,  owing  to  disease  at  a  higher 
level  of  that  medulla,  they  are  completely  paralyzed  to  the  will.  In  these  cases  elec- 
tricity can  accomplish  but  very  little,  and  yet  that  very  little  may  be  of  considerable  service. 
Every  now  and  then  a  certain  group  of  muscles  especially  suffers ;  the  sphincters  of  the 
bladder  and  rectum  are  very  prone  to  be  deranged.  Sometimes  the  expulsive  power  is 
affected,  sometimes  the  sphincter.  It  occasionally  happens  that,  although  you  cannot  in 
the  smallest  degree  affect  the  limbs  of  the  patient,  you  may  give  the  patient  a  little  more 
power  over  the  sphincters.  Probably  the  nutrition  has  failed,  and  the  condition  is  some- 
thing like  that  which  I  have  already  described.  You  may  bring  back  power  enough  to 
make  the  sphincters  competent ;  and  to  do  that  is  to  afford  great  relief.  If  you  want  to 
apply  it  to  the  sphincter  of  the  bowel,  the  best  plan  is  to  put  one  sponge  of  the  faradiza- 
tion machine  over  the  sacrum,  and  the  other,  well  wetted,  to  the  anus ;  and  if  you  want 
to  apply  it  to  the  sphincter  of  the  bladder,  you  place  one  sponge,  well  wetted,  on  the 
perineum,  just  behind  the  scrotum,  and  the  other  over  the  symphysis  pubis.  By  such 
means  you  may  prevent  the  frequent  involuntary  passage  of  evacuations.  I  do  not  say 
that  you  will  do  it  in  all  cases,  but  you  will  in  some. 

But,  again,  you  get  cases  in  which  the  disease  of  the  spinal  cord  is  such  as  to  produce 
only  incomplete  paralysis.  The  limb  is  weak,  the  contractility  is  less  than  natural,  and 
the  nutrition  is  disposed  to  fail.  Can  electricity  do  anything  there  ?  I  think  it  may  do 
a  great  deal ;  these  constitute  the  class  of  cases  in  which  it  does  very  much  good.  But 
here  you  must  observe  the  caution  I  gave  you  in  the  last  lecture, — not  to  use  too  strong 
a  current  of  electricity  during  the  early  days  of  an  acute  illness.  If  you  suppose  the 
patient  to  be  suffering  from  the  effects  of  a  recent  myelitis,  meningitis,  or  haemorrhage 
into  the  cord,  it  is  a  very  foolish  thing  to  galvanize  him.     If,  on  the  other  hand,  disease  is 


5/2  PSYCHOLOGICAL  MEDICINE. 

creeping  up  slowly, — e.  g.,  white  softening,  or  chronic  myelitis,  or  if  it  depends  upon 
syphilitic  meningitis  that  may  have  occurred  some  time  ago,  and  led  to  some  slowly-in- 
duced pressure  on  the  cord, — you  may,  in  such  cases  of  partial  spinal  paralysis,  find  elec- 
tricity very  useful. 

Here  it  is  that  1  would  especially  distinguish  between  the  faradic  and  the  battery-cur- 
rent. Where  there  is  wasting  of  the  limb,  the  application  of  the  battery-current  has  ap- 
peared to  me  much  more  efficacious  and  much  less  mischievous  than  the  other,  when  it 
is  applied  in  the  manner  I  have  described.  When,  on  the  contrary,  there  has  been  no 
such  wasting  of  limb,  it  seems  to  me  that  faradization  has  acted  better, — faradization  ap- 
plied with  wet  sponges,  and  especially  directed  to  the  muscles.  If  the  contractility  of 
a  muscle  is  good,  and  just  in  proportion  as  you  find  the  contractility  of  a  muscle  good, 
your  prognosis  is  bad,  so  far  as  electrical  treatment  is  concerned.  If  you  find,  for  in- 
stance, a  limb  perfectly  paralyzed,  but  contracting  perfectly  well  to  galvanism,  or  some- 
times acting  even  in  excess,  you  can  do  nothing  more  by  applying  galvanism  to  that  limb. 
Your  prognosis  may,  however,  be  good  if  you  find  the  contractility  diminished,  but  not 
lost.  If  it  be  w^holly  lost,  the  prognosis  is  bad;  if  absolutely  good,  the  prognosis  is  bad; 
if  between  the  two,  it  is  in  proportion  to  the  improvement  you  can  effect  in  the  nutritive 
condition  by  one  or  two  applications  of  the  current. 

I  have  to  mention  only  one  other  point  in  these  cases  of  spinal  paralysis, — cases  of  im- 
potence. These  cases  are  sometimes  very  much  improved  by  the  use  of  electricity  ap- 
plied in  the  same  manner  as  for  loss  of  power  over  the  sphincter  vesicae. 

9-  Now  a  few  words  on  paralysis  from  injury  to  or  disease  of  the  nerves, — the  third 
group.  These  cases  are  distinctly  of  the  same  class  as  those  which  Dr.  Marshall  Hall 
called  "  spinal  paralysis."  Some  persons  have  called  them  peripheral,  local,  or  trau- 
matic paralysis.  So  far  as  the  contractility  of  the  muscles  is  primarily  concerned,  it  mat- 
ters not  whether  you  cut  the  nerves  across  or  destroy  the  cord  to  which  tho.«e  nerves  were 
attached.  If  you  divide  a  nerve  going  to  a  muscle, — as,  for  example,  when  the  facial 
nerve  is  divided  by  disease  in  the  bone, — you  have  "  spinal  paralysis  "  of  the  facial  nerve 
in  the  sense  in  which  Dr.  Marshall  Hall  used  that  word.  The  severance  of  muscles 
from  the  spinal  centre  may  be  complete  or  incomplete,  and  you  can  measure  the  amount 
of  damage  done  by  the  amount  of  electric  contractility  that  remains.  If  a  muscle  or  a 
group  of  muscles  has  been  for  a  time  completely  paralyzed  by  a  damage  done  to  a  nerve 
or  by  neuritis,  and  yet  the  morbid  state  of  the  nerve  was  of  such  kind  that  it  might  be 
repaired,  then,  although  the  nerve  has  recovered,  the  results  of  its  disuse  may  remain, 
and  imperfect  paralysis  may  persist.  For  instance,  take  this  example,  which  occurred  to 
myself  not  very  long  ago.  A  man  tried  to  lift  a  heavy  portmanteau,  strained  himself  in 
doing  so,  had  great  pain  in  his  arm  afterwards,  and  then  most  intense,  indeed  agonizing, 
burning  and  tingling  in  the  tips  of  his  fingers  and  palm  of  the  hand.  After  a  time  the 
pain  disappeared,  and  then  it  was  found  that  his  hand  was  excessively  weak  and  that  the 
muscles  were  wasted.  He  had  strained  his  forearm,  injured  its  nerves,  and  set  up  some 
neuritis;  but  after  the  neuritis  passed  away,  there  remained  paralysis  of  the  muscles, 
with  wasting,  and  almost  complete  loss  of  electrical  irritability.  It  was  not  until 
some  time  after  all  these  symptoms  had  occurred  that  he  was  treated  electrically,  and 
then  the  difficulty  to  be  contended  with  was  the  wasted  muscles.  In  looking  at  what  he 
could  do  with  his  hand,  we  found  that  there  was  every  movement  of  the  hand  that  could 
be  performed;  he  could  bend  all  his  fingers,  separate  them,  and  bring  them  together 
again  ;  but  he  could  not  do  this  quickly,  nor  could  he  do  it  forcibly.  There  was  partial 
paralysis  of  all  the  muscles  of  the  hand,  depending  upon  damage  to  the  nerve,  and  also 
upon  consecutive  changes  in  the  muscles.  Electricity  was  applied  to  the  forearm  and 
hand,  and  the  muscles  soon  improved  in  their  nutrition ;  and  with  that  improvement  in 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  573 

the  nutrition  of  the  muscles  the  voluntary  power  returned.  You  may  find  a  similar  thing, 
now  and  then,  in  the  case  of  facial  palsy, — paralysis  persisting  as  the  result  of  disease. 
Examined  electrically,  you  find  that  there  is  a  certain  amount  of  contractility  left,  al- 
though it  is  defective.  If  you  apply  electricity  after  an  interval  of  two  or  three  weeks, 
you  may  often  cure  the  case  by  a  very  few  applications ;  but  if  the  paralysis  has  lasted 
for  six  months,  you  will  find  at  first  very  little  contractility  indeed,  and  you  will  have  to 
apply  electricity  again  and  again  before  you  obtain  any  distinct  marks  of  improvement. 
Sometimes  there  is  slight  restoration  of  voluntary  power  after  even  the  first  or  second 
application,  and  then  the  subsequent  improvement  is  very  trifling  When  the  paralysis 
is  imperfect,  and  the  contractility  is  only  diminished,  you  may  accomplish  much;  but 
when  the  contractility  has  quite  disappeared  there  is  little  or  nothing  that  you  can  do. 
You  never  can  tell,  until  you  have  made  several  applications  of  the  current,  whether  or 
not  the  case  is  curable,  for,  although  a  group  of  muscles  may  be  completely  paralyzed 
to  the  will,  there  may  be  some  few  nerve  tubules  that  have  escaped  destruction,  and  their 
functions  may  be  slowly  recalled. 

The  mode  in  which  you  should  apply  electricity  in  cases  of  local  paralysis  is  the  fol- 
lowing :  Place  one  conductor,  well  wetted,  over  the  trunk  of  the  nerve,  and  the  other 
over  the  muscles,  sa-iatiin.  If  you  are  using  faradization  you  may  keep  the  second 
conductor  steady  ;  if  galvanism,  you  must  move  it  about,  in  order  to  interrupt  the  cur- 
rent. 

Paralysis  of  the  third  nerve,  with  ptosis  or  strabismus,  may  be  treated  by  galvanism  or 
faradism ;  in  either  case  one  pole  should  be  placed  behind  the  ear,  in  the  hand,  or  on  the 
cheekbone,  and  the  other  should  be  applied  to  the  lid.  A  weak  current  only  should  be 
used,  and  the  application  should  be  brief. 

In  paralysis  of  the  seventh  nerve,  from  simple  exposure  to  cold,  the  best  plan  of  using 
electricity  is  the  electric  brush.  Place  a  well-wetted  sponge  behind  the  ear,  and  take  the 
metallic  brush  and  brush  it  over  the  skin  so  as  to  sting  the  face.  If  it  have  existed  longer, 
and  there  be  much  wasting  of  muscle,  the  same  rule  applies;  but  here  you  should  also 
operate  upon  the  muscles,  and  I  would  advise  you  to  use  the  battery-current  for  a  certain 
number  of  times,  until  you  find  that  its  power  of  eliciting  contraction  diminishes,  and  then 
to  apply  faradization. 

10.  And  now  a  word  or  two  about  other  kinds  of  paralysis,  depending  more  or  less 
on  some  morbid  condition  of  blood,  or  nerve,  or  muscle,  or  of  all  these  elements  together. 
And,  first,  let  me  direct  your  attention  to  poisoning  by  lead. 

(a)  I  do  not  know  the  precise  mode  in  which  lead  produces  paralysis,  or  why  it  singles 
out  particular  muscles ;  but,  in  those  muscles  which  are  affected,  it  is  found  that  there  is 
undue  readiness  of  response  to  a  slowly  interrupted  galvanic  current,  and  greatly  dimin- 
ished contractility  to  faradization,  and  to  a  rapidly  interrupted  galvanism.  Whatever 
may  be  the  explanation  of  these  points,  remember  that  it  is  not  simply  a  question  of  dif- 
ference in  the  kind  of  electricity  applied,  for,  if  you  rapidly  interrupt  the  battery-current, 
you  find  the  muscles  in  lead-palsy  do  not  act  to  that.  The  rapidity  of  the  interruption 
may  account  for  the  inaction  of  faradization ;  but,  why  the  muscles  that  are  paralyzed 
should  act  more  readily  than  healthy  muscles  to  a  slowly  interrupted  current,  has  not  yet 
been  explained.  The  mode  of  treating  lead-palsy  has  been  by  faradization,  or,  by  the 
application  of  the  battery-current.  You  take  a  current  from,  say  five  cells,  apply  it  to 
the  extensors  of  the  hand,  and  you  produce  definite  contraction.  After  a  few  applications 
you  often  find  that  five  cells  are  not  enough;  you  have  to  use  seven,  or  eight,  or  ten ;  and 
in  a  few  weeks  of  apphcation  you  have  to  use  quite  as  many  to  produce  contraction  as  in 
a  healthy  limb.  At  first  they  are  very  sensitive  to  the  battery-current ;  then  gradually,  as 
you  apply  it,  they  grow  less  so,  and  you  then,  curiously  enough,  find  them  brought  back 


574  PSYCHOLOGICAL   MEDICINE. 

into  their  normal  relationship  to  faradization.  There  is  no  doubt  about  the  fact  that  the 
improvement  in  nutrition,  which  seems  to  be  brought  about  by  the  battery-current  rather 
than  by  any  other  means,  entails  a  loss  of  the  morbid  irritability  to  that  battery-current, 
and  with  that  improvement  in  nutrition  you  get  a  return  of  the  normal  contractility.  If 
you  have  not  a  battery-current,  you  may  use  faradization  to  begin  with ;  but  if  you  do, 
be  quite  sure  that  you  affect  the  muscles.  I  have  known  patients  with  lead-palsy  treated 
by  having  their  hands  in  water  and  their  feet  in  water  while  the  current  is  passed  from 
one  to  the  other.  Such  a  proceeding  is  not  of  the  slightest  good.  If  you  were  to  apply 
one  pole  of  a  faradization  machine  to  the  chimney-pot  of  a  man's  house,  and  the  other 
to  his  door-step,  you  would  be  as  likely  to  get  the  current  into  the  muscles  that  you  want 
to  benefit.  You  must  apply  faradization  locally,  with  thoroughly  well-wetted  sponges, 
and  of  such  low  intensity  that  it  is  scarcely  felt,  and  yet  of  sufficient  strength  for  you  to 
be  certain  the  muscles  respond.  Use  it  every  day,  and  have  particular  muscles  singled 
out — ^just  those  which  are  the  most  paralyzed.  In  these  cases  it  is  often  difficult  to  get 
the  current  into  the  limb,  and  you  will  find  an  advantage  sometimes  in  soaking  the  limb 
by  covering  it,  for  an  hour  or  two  beforehand,  with  wet  lint  and  oiled  silk  at  the  spots 
where  you  want  to  apply  the  sponges.  Get  the  skin  well  moistened,  and  the  current  will 
pass  through  more  readily. 

(b)  One  word  about  the  paralyses  that  come  from  anaemia,  and  are  often  met  with  in 
pale  hysterical  girls.  Some  are  set  down  as  hysterical  without,  I  think,  any  just  cause; 
they  are  more  or  less  dependent,  probably,  on  an  altered  blood  state,  which  may  affect  the 
cerebral  centres  and  lead  to  these  peculiar  weaknesses.  I  am  quite  sure  that  some  of 
these  local  paralyses  are  relieved  occasionally  by  static  electricity  administered  in  the 
mode  I  have  described  already,  by  sparks  from  the  skin,  or  prime  conductor,  or  by  a 
Leyden  phial.  One  of  the  forms  which  anaemic  paralysis  occasionally  takes  is  that  of 
loss  of  speech,  or  change  of  voice,  dysphonia,  or  aphonia.  It  is  often  called  hysterical 
aphonia.  It  may  be  hysterical,  accordmg  to  the  use  of  the  term  by  some  people,  but  in 
many  cases  it  exists  quite  alone  and  apart  from  anything  that  one  ordinarily  recognizes 
as  the  hysterical  temperament.  When  present  there  is  almost  invariably  marked  anaemia. 
Here,  sometimes,  a  few  sparks  from  the  prime  conductor  of  a  machine  will  bring  the 
voice  back  directly.  Sometimes,  if  that  will  not  do,  the  Leyden  phial  will  immediately 
succeed,  and  this  after  you  have  applied  electricity  in  other  forms  without  success.  A  few 
sparks  do  not  cause  pain ;  but  if  you  apply  faradization  to  the  larynx,  you  do  cause  a  great 
deal  of  pain.  It  is  uncomfortable  to  have  even  a  weak  faradic  current  passed  through  the 
larynx,  and  it  is  often  perfectly  unsuccessful ;  and  yet  a  spark,  which  causes  no  distress, 
will  often  bring  back  the  voice  at  once.  In  certain  cases  it  is  desirable  to  introduce  the 
current  of  faradizatien  right  into  the  glottis,  and  this  is  so  when  there  is  distinct  paralysis  of 
the  vocal  cords.  You  may  see  with  the  laryngoscope  that  one  or  the  other  cord  or  that  both 
cords  are  paralyzed  ;  and  it  is  quite  easy  to  apply  faradization  to  the  larynx  internally  in  the 
manner  recommended  by  Dr.  Morell  Mackenzie.  One  pole  is  held  in  the  hand,  or  applied 
to  the  nape  of  the  neck  ;  the  larynx  is  well  exposed ;  and  the  other  pole  is  carried  between 
the  cords  by  an  instrument  constructed  for  this  purpose.  This  is  shaped  like  a  catheter, 
with  a  small  sponge  at  the  end ;  and  this  sponge  has  a  wire  passing  from  it  inside  the 
catheter  up  into  the  handle,  which  is  so  connected  with  a  key  that  you  can  either  make 
or  break  the  current  by  pressing  on  the  key.  Having  placed  the  sponge  in  between  the 
vocal  cords,  you  touch  the  key  and  send  the  current  through  them.  Patients  will  some- 
times cry  out  the  moment  that  the  application  is  made,  and  you  may  very  easily  imagine 
that  they  would  if  they  have  any  crying  power  left  in  them.  But  many  patients  prefer 
the  internal  faradization  of  the  larynx  to  the  external,  affirming  that  it  is  the  less  painful 
of  the  two. 


ELECTRICITY    IN    DISEASES    OF    THE   NERVOUS    SYSTEM.  575 

11.  There  are  a  few  words  only  which  I  wish  to  say  about  local  spasms.  The  forms 
of  spasm  in  which  electricity  has  been  most  commonly  used  are  "  torticollis,"  a  spasmodic 
condition  of  the  muscles  of  the  neck  on  one  side;  "writer's  cramp;"  and  so-called 
"  histrionic  spasm  "  of  the  face.  It  is  said  that  such  cases  have  been  cured,  but  my  own 
experience  has  been  unfortunate  with  regard  to  them.  I  have  tried  electricity  again  and 
again,  and  in  every  available  form,  but  have  never  seen  it  do  any  good.  I  have  tried 
battery-currents,  direct  and  indirect ;  I  have  tried  faradization  weak  and  faradization 
strong,  with  wet  sponges  and  with  dry;  I  have  used  static  electricity  also,  and  each  form 
of  electricity  persistently ;  I  have  not  given  up  because  the  treatment  has  done  no  good 
at  first,  but  I  do  not  know  one  single  instance  in  which  it  ever  seemed  to  me  to  do  the 
smallest  good.  In  torticollis,  for  the  time  being,  you  can  put  the  head  straight  by  either 
a  strong  battery-current  passed  through  the  contracting  muscles  or  by  faradization  of  the 
other  side,  the  muscles  of  which  are  often  weak,  but  directly  you  cease  the  application 
the  head  goes  back  again  to  its  abnormal  position.  I  have  obtained  similar  negative 
results  in  cases  of  both  writer's  cramp  and  histrionic  spasm.  Others  have  been 
more  successful,  and  I  trust  that  your  experience  may  resemble  theirs  rather  than 
my  own. 

12.  In  painful  affections,  such  as  the  neuralgiae,  migraine,  sciatica,  tic  doloreaux,  and 
the  like,  and  also  in  some  conditions  of  modified  sensibility,  such  as  the  spontaneous 
feeling  of  heat  or  cold,  the  sense  of  numbness,  of  tingling,  "  pins  and  needles,"  or  such 
like  discomforts,  electricity  is  often  of  considerable  service.  It  is  the  continuous  gal- 
vanic current  which  you  should  use,  and  it  should  be  of  only  such  strength  as  to  be  just 
perceptible  by  the  patient ;  it  should  be  applied  to  the  part  with  well-wetted  sponges, 
and  should  be  applied  for  a  short  time  only,  but  with  frequent  repetition.  I  know  of 
nothing  more  distinct  or  more  satisfactory  in  therapeutics  than  the  relief  which  may  often 
thus  be  given  to  suffering  of  the  most  intense  character,  the  relief  being  very  rapidly  in- 
duced and  in  many  cases  permanent.  In  applying  galvanism  to  the  head  you  must  be 
very  careful  to  avoid  using  such  a  strength  as  to  cause  vertigo  or  faintness,  and  I  am  sure 
that  you  may  avoid  these  evils  by  trying  the  current  upon  your  own  head  first,  and  then 
by  carefully  observing  the  patient  and  stopping  the  application  for  a  time  the  moment 
that  there  is  any  complaint,  by  word,  gesture,  or  look,  of  any  uneasiness  in  the  head  or 
epigastrium. 

Electricity  is  one  of  the  most  powerful  agents  that  you  can  employ  in  the  treatment  of 
disease;  but  it  is  useful,  useless,  or  mischievous,  according  to  the  manner  in  which  it  is 
applied,  and  my  endeavor  has  been  to  furnish  you,  by  means  of  these  lectures,  with  the 
information  which  shall  enable  you  to  derive  help  from  it  in  diagnosis  and  confer  real 
advantage  upon  your  patients  by  rightly  directing  its  therapeutic  powers. 

Respecting  the  comparative  value  of  the  galvanic  and  faradic  cur- 
rents, Dr.  A.  D.  Rockwell,  of  New  York,  says  : 

Since  the  time  of  Remak  the  comparative  value  of  the  galvanic  and  faradic  currents  in 
therapeutics  has  excited  considerable  interest,  and  at  one  time  was  the  subject  of  angry 
controversy.  At  the  present  day  all  electro-therapeutists  who  keep  abreast  of  the  pro- 
gress of  their  department  agree  that  both  currents  are  of  service,  that  one  will  fulfil  cer- 
.tain  conditions  for  which  the  other  is  inadequate,  and  that  no  one  who  expects  to  secure 
in  practice  the  complete  effects  of  electrization  can  dispense  with  either.  Concerning  the 
special  indications  for  the  use  of  the  one  or  the  other,  opinions  widely  and  honestly  differ 
according  to  the  opportunities  and  experience  of  each  individual.     In  Germany,  where 


5/6  PSYCHOLOGICAL    MEDICINE. 

the  school  of  Remak  is  dominant,  the  galvanic  is  used  more  than  the  faradic ;  in  France, 
at  least  among  the  disciples  of  Duchenne,  the  faradic  more  than  the  galvanic.  In  Eng- 
land and  America  both  currents  are  employed,  general  practitioners  using  chiefly  the 
faradic,  while  specialists  use  both  with  more  or  less  exclusiveness. 

Much  of  the  confusion  that  exists  concerning  the  differential  indications  for  the  use  of 
the  galvanic  or  faradic  currents  arises  from  an  imperfect,  or  erroneous,  or  exaggerated 
conception  of  the  distinctions  in  their  physiological  effects. 

The  general  belief  or  supposition  is  that  there  is  between  them  a  radical  and  important 
difference  in  khid,  and  that  an  appreciation  of  this  distinction  is  essential  for  a  knowl- 
edge of  the  differential  indications  for  their  use.  From  the  accumulating  results  of  ex- 
periment and  experience  in  electro-physiology,  diagnosis,  and  therapeutics,  we  think  that 
there  is  strong  reason  for  regarding  the  essential  distinction  in  the  effects  of  these  cur- 
rents on  the  body  as  mainly  of  degj-ee,  and  that  this  is  the  scientific  basis  for  their  differ- 
ential employment. 

Thus  the  galvanic  current,  applied  on  the  face  and  head,  produces  flashes  before  the 
retina,  while,  as  a  rule,  the  faradic  will  not.  We  have,  however,  frequently  treated  cer- 
tain sensitive  pathological  conditions  where  the  same  flashes  were  caused  by  the  faradic. 
With  the  improvement  in  the  general  condition  of  such  patients,  this  unusual  suscepti- 
bility to  the  faradic  influence  always  disappears.  An  important  peculiarity  of  the  gal- 
vanic cmTent  is  that,  when  applied  on  the  neck,  it  causes  a  metallic  taste,  and  yet  we 
have,  on  several  occasions,  treated  cases  of  constitutional  neuralgia  combined  with  exces- 
sive irritability,  where  the  same  effect  was  markedly  and  even  unpleasantly  produced  by 
the  faradic  current  when  applied  above  the  seventh  cervical  vertebra.  Other  well- 
recognized  peculiarities  in  the  effects  of  the  galvanic  current,  distinguishing  it  from 
those  of  the  faradic  are  giddiness  and  vertigo  when  applied  on  or  near  the  head,  di- 
plegia contractions  and  special  sensations  down  the  upper  extremities  and  over  the 
body  when  applied  to  the  cervical  sympathetic ;  marked  chemical  effects,  especially 
when  used  in  large  quantity,  redness  and  burning  sensations  of  the  skin  at  the  points 
on  the  surface  where  the  electrodes  are  applied.  All  of  these  effects  are  observed  in 
a  less  degree  from  the  faradic  current,  and  some  of  them  in  cases  of  great  abnormal 
.sensitiveness  are  very  decided.  When  we  come  to  study  their  therapeutic  effects  we 
also  find  that  both  currents  differ  chiefly  in  degree.  In  the  form  of  localized  electriza- 
tion both  can  produce  muscular  contractions  in  paralyzed  muscles  and  relieve  local  neu- 
ralgia ;  both  cause  absorption  of  abnormal  secretions  and  both  can  directly  affect  the 
brain,  spinal  cord,  sympathetic,  and  all  the  internal  organs,  producing  in  different  de- 
grees, the  various  therapeutic  results  that  directly  and  indirectly  flow  from  electrical  ex- 
citation of  these  parts.  In  the  form  of  general  electrization  both  currents,  besides  producing 
most  of  the  results  of  localized  electrization,  act  as  powerfully  stimulating  tonics,  and  thus 
form  most  efficient  aids  in  the  relief  and  cure  of  nervous  exhaustion,  nervous  dyspepsia, 
constitutional  neuralgia,  and  of  a  wide  range  of  nervous  diseases  associated  with  or  de- 
pendent on  general  debility. 

In  electro-surgery  both  currents  avail  to  discuss  tumors,  heal  ulcers,  and  hasten  ab- 
sorption, although  the  galvanic  current,  -when  used  in  large  quantity,  produces  cauter- 
izing effects  to  which  the  faradic  is  unequal.  And  yet  the  difference  in  a^^^r^^  between 
the  effects  of  the  two  currents  is  so  marked  and  so  clearly  demonstrable  as  to  be  practi- 
cally equivalent  in  certain  instances  to  a  difference  in  kind,  and  to  give  very  important 
and  remarkable  advantages  to  one  current  or  the  other,  according  to  the  indications 
offered. 

Advantages  of  the  Galvanic  over  the  Faradic  Current. — The  advantages  of  the  gal- 
vanic over  the  faradic  current  are  : 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  5// 

1st.  A  greater  power  of  overcoming  resistance. 

It  therefore  affects  the  brain,  spinal  cord  and  sympathetic  more  powerfully  than  the 
faradic,  since  the  anatomical  position  of  these  parts  is  such  that  considerable  resistance 
must  be  overcome  in  order  to  directly  affect  them. 

For  the  same  reason,  it  is  usually  to  be  preferred  when  it  is  desired  to  affect  the  mid- 
dle and  internal  ear,  the  retina  and  the  rnuscles  of  the  eye. 

2d.  A  power  of  producing  muscular  co7itractions  in  cases  where  the  faradic  fails. 

This  peculiarity  of  the  galvanic  current  has  been  observed  so  frequently,  and  in  such 
striking  instances,  that  it  has  become  an  accepted  fact  of  electro-therapeutical  science. 

After  a  certain  amount  of  treatment  by  the  galvanic  current,  the  paralyzed  muscles 
frequently  resume  their  susceptibility  to  the  faradic. 

3d.  A  different  and  far  more  potent  chemical  action. 

The  chemical  power  of  the  galvanic  current  is  most  markedly  seen  when  used  for  the 
purpose  of  galvano-cautery,  or  "  galvano-caustic  chemique." 

In  order  to  produce  the  energetic  caustic  effects  of  the  galvanic  current,  it  is  necessary 
to  use  elements  that  generate  quantity  of  electricity,  and  to  combine  them  in  such  a  way 
that  the  quantity  produced  shall  be  very  large,  since  an  ordinary  single  element,  or  in- 
deed, a  large  number  of  elements  arranged  for  intensity,  exhibit  only  a  comparatively 
feeble  cauterizing  effect.  It  is  because  the  galvanic  current  can  be  thus  arranged  for 
quantity,  more  than  in  any  difference  in  kind  between  the  effects  of  the  two  currents, 
that  it  has  so  marked  and  peculiar  a  superiority  to  the  faradic  as  to  practically  amount  to 
a  difference  in  kind.  The  quantity  of  the  faradic  can  be  but  slightly  increased,  and 
hence,  although  it  does  possess  some  chemical  virtues  and  produces  slight  chemical  ef- 
fects, it  is  not  indicated  where  such  effects  must  be  very  energetic  or  concentrated.  The 
superior  efficacy  of  the  galvanic  current  to  the  faradic,  so  often  observed  in  the  treatment 
of  neuralgia,  of  atrophied  muscles,  rheumatism,  etc.,  is  probably  due  to  its  greater  chem- 
ical or  catalytic  action.  It  probably  induces  more  rapid  and  more  important  molecular 
and  other  changes  in  the  tissues. 

Advantages  of  the  Faradic  over  the  Galvanic  Ctirrent. — The  advantages  of  the  faradic 
over  the  galvanic  current  are  these  : 

1st.  By  virtue  of  its  frequent  interruptions  it  more  easily  produces  muscular  contrac- 
tions when  passed  over  the  muscles  or  the  nerves  that  supply  them.. 

In  order  to  produce  muscular  contractions  with  the  galvanic  current,  it  is  necessary  to 
interrupt  the  current,  and  unless  it  is  quite  powerful,  to  localize  at  least  one  of  the  elec- 
trodes over  the  motor  nerve  by  which  the  muscle  is  supplied.  On  the  contrary,  the  far- 
adic current  is  in  a  condition  of  rapid  interruptions,  and  produces  contractions  when  in- 
differently passed  over  the  surface  of  the  muscle,  as  well  as  when  localized  on  the  main 
motor  nerve  that  supplies  it.  This  advantage  of  the  faradic  current  is  best  appreciated 
in  general  electrization,  the  powerful  tonic  effects  of  which  are  partly  and  quite  largely 
due  to  the  passive  exercise,  and  consequently  important  changes  of  tissue  that  result 
from  the  several  thousand  muscular  contractions  that  take  place  during  an  ordinary  sit- 
ting. In  localized  electrization  this  advantage  is  not  so  clearly  or  strongly  marked,  since 
in  this  method,  by  a  proper  knowledge  of  electro-therapeutical  anatomy  and  sufficient 
care,  it  is  possible  to  direct  one  of  the  electrodes  on  the  motor  points ;  and  yet  even  here 
the  faradic  current  is  much  more  convenient,  because  its  employment  requires  no  ar- 
rangement for  interruptions  and  less  minuteness  of  attention  to  the  situation  of  the  "  motor 
points."  The  exceptional  cases  of  paralysis,  where  the  muscles  have  lost  their  suscep- 
tibility to  the  faradic  current,  do  not  interfere  with  the  general  rule. 

2d.  It  is  less  likely  to  produce  unpleasant  or  ha7'mful  effects  than  the  galvanic. 

In  certain  acute  and  chronic  pathological  conditions,  where  it  is  desirable  to  produce 

37 


578  PSYCHOLOGICAL    MEDICINE. 

a  decidedly  stimulating  effect  without  marked  catalytic  action,  the  faradic  current  can 
alone  be  used  with  benefit  and  safety.  To  confirm  this  statement,  we  rest  mainly  on  the 
evident  results  of  clinical  observation.  We  recall  at  least  two  cases  of  severe  neuralgia 
of  the  trigeminus,  where  a  mild  and  rapidly  interrupted  faradic  current,  applied  on  sev- 
eral occasions,  relieved  the  pain  very  decidedly. 

In  order  to  hasten  recovery,  the  constant  current  from  but  four  of  Bunsen's  cells  was 
for  a  moment  directed  along  the  course  of  the  painful  nerve.  In  both  instances  the 
neuralgia  immediately  returned  with  increased  severity,  but  was  relieved  a  second  time, 
and  soon  recovered  under  the  influence  of  the  current  first  named.  We  may,  indeed, 
refer  to  a  number  of  cases  of  severe  constitutional  neuralgia  and  excessive  nervous  exhaus- 
tion where  the  faradic  current  invariably  relieved,  and  where  the  galvanic  as  invariably 
aggravated  the  symptoms. 

Our  own  experience  teaches,  that  wherever  the  constant  current  can  be  used  without 
injury,  there  also  will  a  faradic  current  of  relative  intensit)'  be  harmless.  It  teaches  fur- 
ther, as  above  stated,  that  in  certain  conditions,  where  the  faradic  current  is  not  only 
harmless,  but  of  decided  benefit,  the  galvanic,  even  when  its  tension  is  verj^  slight,  may 
occasion  evil  results. 

Galvanization  of  the  Sympathetic. — One  of  the  most  important  advantages  possessed 
by  the  galvanic  over  the  faradic  current  is  the  readiness  with  which  the  former  affects 
the  sympathetic. 

The  attention  of  the  profession  was  first  called  to  this  fact  by  Remak,  who  observed 
the  occurrence  of  diplegic  contractions  when  the  superioi  cervical  sympathetic  was  sub- 
mitted to  the  influence  of  the  constant  current. 

This  observation  of  Remak  was  confirmed  by  Fieber,  who  produced  similar  phenom- 
ena in  the  living  animal  by  exposing  the  sympathetic  and  directly  galvanizing  it. 

It  does  not  come  within  the  scope  of  this  short  paper  to  theorize  at  length  concerning  the 
beneficial  results  following  galvanization  of  the  sympathetic. 

In  those  cases  of  paralysis  of  vasomotor  nerves  and  arterial  spasm  that  are  benefited 
by  this  method  of  treatment,  the  favorable  results  may  be  asci'ibed  in  brief  to  the  influ- 
ence exerted  on  the  vasomotor  nerves. 

The  few  following  cases  may  serve  to  illustrate  some  points  in  the  above  remarks  : 
Case  of  Persistent  and  Excessive  Nausea. — Recovery  follows  Galvanization  of  the 
Sympathetic. — Mr.  H.  S.,  a  tall  spare  man,  aged  49,  was  the  \dctim  of  a  mild  form  of 
nervous  dyspepsia,  from  which  he  had  suffered  slightly  for  many  years.  Some  three 
years  since,  a  very  annoj-ing  symptom  super^^ened.  Every  morning  soon  after  break- 
fast he  observed  a  feeling  of  nausea,  that  lasted  a  short  time  and  then  passed  away. 

This  symptom  gradually  increased  in  severity  and  duration,  until  it  became  most  dis- 
tressing, and  for  more  than  two  years  no  form  of  medication  had  afforded  more  than 
temporary  relief.  We  first  made  use  of  the  faradic  current  by  the  method  of  general 
electrization,  directing  the  applications  more  especially  to  the  back  of  the  neck,  so  as  to 
affect,  as  far  as  possible,  the  sympathetic.  As  no  relief  followed,  we  resorted  to  the 
galvanic  current,  applying  the  positive  pole  at  the  inner  border  of  the  sterno-cleido-mas- 
toideus  muscle,  and  the  negative  at  the  sixth  cervical  vertebra,  and  allowed  a  inild  un- 
interrupted current  to  pass  for  three  minutes.  By  this  method  the  sympathetic  was  de- 
cidedly influenced,  and  relief  was  afforded.  Succeeding  applications  gradually  reduced 
the  intensity  of  the  nausea  until  the  tenth  seance,  when  it  disappeared  completely  and 
has  not  since  returned. 

Case  of  Disordered  Nervous  Action  relieved  by  Galvaiiizatioti  of  the  Sympathetic. — Mr. 
H.,  aged  40,  complained  of  an  unpleasant  feeling  of  constriction  in  the  throat,  and  a 
constant  pricking  or  tingling  in  the  arms  and  hands.     The  patient,  who  M'as  of  a  highly 


ELECTRICITY   IN    DISEASES    OF   THE   NERVOUS    SYSTEM.  5/9 

nervous  organization,  stated  that  these  symptoms  had  existed  for  a  number  of  years. 
During  the  last  few  months,  however,  they  had  become  so  decidedly  aggravated  as  to 
excite  alarm,  and  impelled  him  to  seek  professional  advice. 

A  number  of  general  applications  with  the  faradic  current  were  administered  without 
special  result.     We  then  resolved  to  influence  the  sympathetic  by  the  galvanic  current. 

The  first  application  to  either  cervical  sympathetic  excited  a  decided  perspiration  in 
both  axillse  and  along  the  inner  side  of  the  arms.  The  symptoms  of  which  he  com- 
plained became  rapidly  less  marked,  and  after  twelve  applications  ceased  to  annoy  him. 

Patients  suffering  from  cerebral  effusions  frequently  speak  of  an  unpleasant  roughness 
in  the  eye.  This  symptom  may  probably  be  ascribed  to  dilatation  of  the  smaller  blood- 
vessels through  weakness  of  the  vasomotor  nerves.  We  have  found  that  this  condition 
is  almost  invariably  relieved  by  galvanization  of  the  cervical  sympathetic. 

^n  Aggravated  Case  of  Chorea  resists  the  Action  of  the  Galvanic,  but  yields  to  General 
Electrization  with  the  Faradic  Current. — The  little  patient  in  whose  case  the  results  of 
treatment  by  the  faradic  currrent  were  so  gratifying,  was  under  the  professional  care  of 
Dr.  J.  O.  Farrington. 

Dr.  George  T.  Elliot  was  called  in  consultation,  and  by  these  gentlemen  electricity 
was  advised. 

Some  two  months  previous  to  the  consultation  certain  abnormal  movements,  such  as 
starting  suddenly  to  his  feet,  throwing  out  a  hand  or  a  foot,  etc.,  were  observed  by  the 
teacher  of  the  boy.  Two  weeks  subsequently  the  patient  was  seized  with  well-marked 
choreic  symptoms  of  the  right  side  of  the  body,  and  in  two  days  the  disturbance  ex- 
tended to  the  opposite  side.  So  constant  and  violent  were  the  movements  of  his  arms 
and  legs  that  it  was  impossible  to  keep  him  on  a  bed  or  sofa.  It  was  necessary  to  place 
him  on  the  carpet,  surrounded  by  inflated  rubber  bags.  Intelligence  seemed  to  be  per- 
fect, but  the  power  of  speech  was  lost,  and  the  sufferer  made  known  his  wants  by  impa- 
tient cries  and  ill-directed  motions. 

Sleep  was  impossible  without  the  nightly  administration  of  an  opiate.  Contrary  to  our 
judgment,  but  by  suggestion,  we  commenced  treatment  by  the  use  of  a  mild  galvanic  cur- 
rent directed  especially  to  the  base  of  the  brain  and  the  spinal  tract;  but  this  method 
served  only  to  aggravate  the  child's  condition.  We  then  resorted  to  the  faradic  current 
by  the  method  of  general  electrization,  but  so  violent  were  the  involuntary  movements 
in  the  limbs  and  body  of  the  patient  that  it  was  with  difficulty  that  he  could  be  held  in 
a  sitting  posture  and  his  feet  kept  on  the  copper-plate  to  which  the  negative  pole  was 
attached.  The  applications  were  general, — every  portion  of  the  body,  from  the  head  to 
the  feet,  being  influenced  on  each  occasion. 

Improvement  was  manifest  from  the  very  first.  He  was  at  once  enabled  to  sleep 
soundly,  although  his  opiate  was  reduced  one-third,  and  after  the  fourth  application  it 
was  dispensed  with  altogether.  In  the  course  of  three  weeks,  during  which  time  fifteen 
applications  were  given,  the  case  was  so  far  improved  that  the  patient  was  able  to  utter 
distinctly  words  and  sentences.  The  choreic  symptoms  were  so  much  diminished  that 
the  boy  could  readily  sit  quiet  and  alone,  and  during  an  application  was  able  to  command 
the  movements  of  his  body  and  feet.  Improvement  continued  during  the  administration 
of  a  few  more  applications,  when  the  child  was  taken  to  the  seashore,  where  in  two  weeks 
he  quite  recovered.  Some  three  months  since,  after  having  enjoyed  excellent  health  for 
a  year  and  a  half,  the  boy  suffered  from  a  second  attack.  He  was  immediately  subjected 
to  the  influence  of  electrization,  and  recovered  even  more  rapidly  than  before. 

Respecting  the  therapeutical  uses  of  galvanism,  Dr.  Samuel  Wilks, 
F.R.S.,  Physician  to  Guy's  Hospital,  says: 


580  PSYCHOLOGICAL    MEDICINE. 

It  must  be  generally  admitted  that  the  therapeutical  uses  of  galvanism  have  received 
a  fresh  impulse  since  the  introduction  of  the  continuous  current  into  practice.  Until  a 
few  years  ago  the  only  method  in  use,  except  frictional  electricity-,  was  that  of  faradiza- 
tion. This  was  sometimes  beneficial,  but  as  often  quite  valueless,  so  that  galvanism  was 
either  indiscriminately  recommended  in  all  forms  of  paralysis  or  was  systematically 
neglected.  A  very  different  feeling,  however,  prevails  at  the  present  time,  for  we  are 
beginning  to  discern  in  what  cases  faradization  is  useful,  and  in  what  cases  it  fails ;  more 
particularly  has  it  been  noticed  that  it  is  in  those  very  cases  where  faradization  has  been 
useless  that  the  continuous  battery  current  has  been  so  fruitful  of  results.  We,  some 
years  ago,  introduced  into  our  electrifying  room  a  large  battery  in  which  any  number  of 
cells  up  to  100  could  be  combined,  and  with  this  instrument  we  have  witnessed  a  success 
in  many  cases  which  scarcely  could  have  been  anticipated.  We  have  a  large  number  of 
patients  daily  being  operated  upon,  and  two  or  three  attendants  constantly  employed 
either  in  the  room  or  in  the  wards.  It  has  not  yet  been  satisfactorily  determined  why 
one  form  of  galvanism  should  fail  to  stimulate  a  muscle  and  be  useless  as  a  remedy, 
whilst  another  form  excites  it  to  contraction  and  is  curative.  This  may  be  dependent 
upon  the  condition  of  the  muscle  or  of  the  nerve  which  supplies  it,  or  the  centre  whence 
the  nerve  springs  ;  at  the  present  time  the  facts  themselves  are  not  sufficiently  established, 
but  when  they  are  so  we  shall  be  able  to  use  them  as  a. means  of  diagnosis.  All  I  shall 
attempt  to  do  here  will  be  to  state  some  of  the  facts  we  have  observed,  and  thus  offer  a 
small  contribution  towards  the  material  out  of  which  some  more  important  conclusions 
may  be  eventually  framed. 

In  the  first  place,  we  had  no  sooner  possessed  our  battery  than  we  discovered  its 
marked  value  in  cases  of  simple  paralysis  of  the  limb.  In  these  cases  faradization  often 
fails  to  produce  the  slightest  effect,  whereas  the  application  of  the  continuous  current 
immediately  excites  the  muscles  to  contraction,  and  eventually  brings  about  a  cure.  A 
good  case  of  the  kind  I  give  below.  Then,  again,  in  various  forms  of  paraplegia  its 
good  effects  have  been  most  striking.  As  I  have  before  said,  it  is  most  difficult  to  ascer- 
tain, in  various  forms  of  paralysis,  whether  an  organic  disease  of  the  cord  exists  or  not, 
seemg  that  all  the  symptoms  which  attend  it  may  occur  in  the  case  which  is  functional 
and  curable,  and  therefore  it  is  true  that  galvanism  has  been  used  in  many  cases  and 
failed ;  but,  on  the  other  hand,  we  have  had  a  variety  of  cases  which  may  be  included 
under  the  term  paraplegia,  where  a  complete  cure  has  been  effected  by  applying  the 
current  to  the  back.  In  some  cases  of  locomotor  ataxy  I  have  witnessed  perfect  recovery, 
both  in  hospital  and  private  practice  ;  also  in  cases  of  commencing  progressive  muscular 
atrophy.  In  paralysis  agitans  I  never  saw  much  good  done  by  faradization  or  any  other 
remedy,  but  in  a  case  I  mention  below  it  appeared  as  if  much  benefit  might  accrue  from 
the  use  of  a  continuous  galvanic  current  down  the  spine.  In  no  case  is  the  effect  of  the 
continuous  current  to  the  limb  so  remarkable  as  in  the  atrophic  paralysis  from  lead,  two 
examples  of  which  I  shall  presently  relate.  The  fact  has  now  for  some  time  been  ob- 
served that  the  muscles  in  this  affection  are  not  susceptible  to  the  interrupted  current  or 
faradization,  that  a  painful  amount  of  it  may  be  used  and  yet  there  shall  be  no  response 
on  the  part  of  the  muscle.  I  have  had  several  cases  in  the  hospital  which  completely 
establish  the  fact.  On  the  other  hand,  if  the  continuous  battery  current  is  used,  even  in 
a  mild  degree,  excitation  immediately  occurs ;  that  is,  when  the  current  is  completed  and 
again  broken. 

In  the  very  first  case  on  which  I  experimented,  some  years  ago,  we  found  in  the  case 
of  a  young  man  suffering  from  lead  paralysis  that,  whereas  no  iiTitation  of  muscle  could 
be  displayed  by  the  magneto-electric  machine,  immediate  contraction  took  place  on  the 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  58 1 

application  of  fifteen  cells  of  the  battery,  an  amount  which  produced  a  scarcely  percep- 
tible effect  on  the  arm  of  a  healthy  student. 

It  is  observed  that  as  the  cure  progresses  so  the  susceptibility  to  the  continuous  current 
becomes  less,  and  that  to  faradization  greater,  until,  as  in  the  healthy  subject,  both  forms 
cause  contraction  of  the  muscles.  The  case  of  lead  is  very  striking,  because  there  are 
kinds  of  paralysis  in  vv'hich  the  two  forms  of  galvanism  act  in  the  opposite  manner;  thus, 
lying  in  a  bed  near  that  of  our  patient,  who  was  the  victim  of  lead  poisoning,  was  a  girl 
suffering  from  old-standing  spinal  paraplegia;  in  her  case  the  continuous  current  pro- 
duced not  the  slightest  effect  in  stimulating  the  muscles  of  the  leg,  whilst  faradization 
produced  strong  and  painful  contractions  of  the  muscles.  The  same  occurred  in  a  man 
who  had  long  been  bedridden  with  an  incurable  paraplegia.  It  has  been  thought  that 
faradization  acts  directly  upon  the  muscle  to  stimulate  it,  whilst  the  continuous  current 
acts  through  the  nerve.  This  has  by  no  means  been  proved,  but  if  it  had,  it  might  be 
used  as  an  argument  that  in  lead  poisoning  it  is  the  muscular  rather  than  the  nervous 
system  which  is  affected  by  the  metal.  Such  an  opinion,  however,  is  not  borne  out 
by  experience,  seeing  that  the  whole  cerebro-spinal  centres  may  become  atrophied  in 
plumbism,  as  evidenced  by  epilepsy,  general  paralysis,  or  dementia.  The  atrophy  re- 
sulting from  lead  differs  from  that  which  is  called  idiopathic  in  this  respect,  that  although, 
in  the  two  cases  no  difference  is  observable  in  the  form  of  wasting,  yet  in  the  latter  there 
is  very  little  susceptibility  to  either  form  of  galvanism.  It  has  been  suggested  by  Dr. 
Russell  Reynolds  that  there  is  no  essential  difference  between  the  primary  and  the  in- 
duced current,  but  that  the  simple  interruption  in  the  one  case  is  sufficient  to  account 
for  its  peculiar  effect ;  that  muscles  under  abnormal  conditions  may  not  be  able  to  take 
cognizance  of  a  simple  current  passing  through  them,  whereas  they  would  if  it  were 
broken.  If  this  were  so,  the  primary  battery  current,  if  interrupted,  should  produce  the 
same  effect  as  the  ordinary  induced  current  or  faradization.  In  one  or  two  cases  where 
the  experiment  was  tried,  the  result  did  not  verify  the  suggestion.  Where,  for  instance, 
one  pole  was  placed  just  below  the  elbow,  and  the  other  pole  stroked  down  the  arm,  a 
contraction  took  place  when  it  was  lifted  from  the  limb  or  again  replaced.  The  current 
was  then  interrupted  by  a  wheel,  but  exactly  the  same  phenomena  occurred,  contraction 
on  making  and  breaking  contact,  but  none  whatever  as  the  sponge  was  stroked  down  th« 
arm.  With  faradization,  on  the  contrary,  violent  contraction  took  place.  In  this  case, 
therefore,  the  difference  between  the  two  forms,  even  when  both  were  made  to  intermit, 
seemed  well  marked.  Further  observations,  however,  are  required  before  I  could  give 
a  decision  on  this  matter,  either  for  or  against  the  suggestion  of  Dr.  R.  Reynolds. 

I  have  already  spoken  of  the  intractability  of  cases  of  spasm  and  contraction  of  the 
muscles.  In  many  cases  oi'ganic  disease  of  the  spinal  cord  and  nerves  exists,  and,  there- 
fore, no  result  could  be  expected;  but  even  in  others,  as  in  wryneck,  where  an  immediate 
effect  of  galvanism  was  witnessed,  no  permanent  good  resulted  from  its  use.  Even  in 
cases  of  so-called  hysterical  contraction  of  the  arm  I  have  been  much  disappointed  at  the 
failure  of  galvanism. 

The  effects  on  the  muscles  in  the  cases  of  spasmodic  contraction  is  seen  in  the  reports, 
in  which  it  appears  that  they  are  more  susceptible  to  faradization  than  to  the  continuous 
current. 

One  must  not  forget  to  mention  the  soothing  effect  of  galvanism.  In  cases  where 
neuralgic  pains  have  existed,  patients  have  expressed  themselves  as  much  relieved  by  its 
application,  and  have  often  slept  better  afterwards. 

The  public  is  so  much  impressed  with  the  value  of  electric  baths  that  I  proposed  to 
try  it  in  a  case  of  lead  poisoning.  I  am  aware  that  others  have  pronounced  it  to  be 
valueless,  which  in  all  probability  is  the  case,  there  -being  no  proof  that  the  galvanic 


582  PSYCHOLOGICAL    MEDICINE. 

current  passes  anywhere  but  over  the  surface  of  the  body.  In  my  case  the  speedy  success 
was  so  remarkable  as  to  throw  strong  suspicion  on  its  having  had  any  value  at  all. 

I  give  the  case  below  with  the  mode  of  use.  Usually,  I  believe,  the  plan  has  been  to 
place  the  patient  on  an  isolated  stool  in  the  water,  with  one  pole  in  his  hand,  the  other 
being  attached  to  the  bath.     In  the  present  case  Mr.  Sandy  used  a  different  method. 

Case  i.  Paralysis  of  Leg. — George  W.,  set.  36,  admitted  into  Stephen  Ward  June 
19th,  for  weakness  of  the  left  leg,  and  left  July  23d.  This  man  was  the  subject  of  a 
remarkable  enlargement  of  the  veins  on  the  surface  of  the  abdomen,  indicating  some 
obstruction  to  the  vena  cava.  He  had  observed  this  fourteen  years,  but  it  had  given  him 
no  inconvenience  nor  interfered  with  his  employment. 

Patient  stated  that  in  March  last  he  was  seized  with  very  acute  pains  through  the  left 
hip  and  groin,  which  gradually  spread  down  the  leg,  and  these  pains  were  worse  at  night. 
Went  to  Swansea  Hospital,  where  knee  became  contracted,  and  he  took  to  crutches. 
He  was  then  sent  up  to  Guy's  Hospital.  He  was  put  to  bed,  being  quite  unable  to  walk, 
on  account  of  pains  and  weakness  in  the  left  leg.  On  examination,  no  local  cause  was 
discoverable  for  the  symptoms;  the  leg  was  somewhat  drawn  up,  it  was  perceptibly 
wasted,  being  smaller  than  the  other,  and  sensation  slightly  impaired.  On  testing  the 
limb,  the  muscles  were  found  to  respond  to  both  the  faradic  and  galvanic  currents.  He 
was  then  ordered  the  continuous  current,  to  be  applied  daily  to  front  and  back  of  thigh. 
After  the  first  application,  he  expressed  himself  as  having  much  relief  from  the  pain,  and 
in  a  few  daj'S  it  had  altogether  left  him.  At  the  same  time  the  strength  returned  in  the 
muscles,  so  that  in  a  few  days  more  he  could  walk.  The  current  was  still  applied,  with 
a  daily  improvement  in  the  strength  of  his  leg,  so  that  on  July  loth  he  was  walking  about, 
and  on  the  21st  he  sufficiently  recovered  to  be  able  to  leave  the  hospital  convalescent 
and  nearly  well.     Patient  took  no  medicine. 

Case  2.  Pai-alysis  Agitmis. — J.  B.,  set.  40,  had  been  suffering  for  three  years  from 
paralysis  agitans.  The  complaint  commenced  in  the  right  hand,  afterwards  proceeded  to 
the  left,  and  then  to  the  legs,  until  a  general  tremor  of  the  whole  body  took  place,  in- 
cluding the  face,  and  affecting  the  speech.  He  had  been  under  different  kinds  of  treat- 
ment, but  without  any  benefit.  I  wished  to  try  the  continuous  galvanic  current  to  the 
spine,  and  accordingly  fifty  cells  (Cruikshank's)  were  used  for  ten  days.  After  the  second 
application  the  patient,  who  had  previously  had  very  restless  nights,  obtained  refreshing 
sleep.  After  four  or  five  applications  he  began  to  experience  a  decided  benefit,  saying 
he  always  felt  lighter  and  steadier  directly  he  had  begn  operated  upon.  The  duration  of 
this  improvement  lengthened  day  by  day.  The  patient  then  left  for  the  country  and  has 
not  since  been  heard  of. 

Case  3.  Lead-  Paralysis. — ]\Ir.  S.,  a  gentleman  of  middle  age,  was  brought  to  me  on 
March  nth,  1872,  by  Dr.  Charlton,  of  Fareham,  suffering  from  a  most  severe  form  of 
lead  paralysis.  His  whole  frame  was  attenuated  in  consequence  of  the  atrophy  which 
his  muscular  system  had  undergone ;  his  limbs  were  very  much  wasted,  and  he  was  pro- 
portionately enfeebled.  He  tottered  when  he  walked;  his  hands  shook,  and  were  so 
weak  that  he  with  difficulty  could  raise  them  to  his  head  or  button  his  coat.  He  resem- 
bled, indeed,  the  condition  of  a  man  with  progressive  muscular  atrophy,  only  in  this  case 
it  was  induced  by  lead  and  was  not  idiopathic. 

The  history  which  he  gave  of  his  case  was  as  follows  :  He  lived  in  Surrey,  about 
twenty  miles  from  Loudon,  and  had  enjoyed  good  health  until  June,  1S71,  when  his 
arms  and  hands  became  tremulous,  so  that  very  shortly  he  was  obliged  to  use  both  hands 
to  raise  fluids  to  his  mouth  to  prevent  spilling.  He  was  recommended  a  change  of  air, 
and  took  a  trip  to  Scotland.  After  being  there  a  month  he  got  considerably  better  and 
returned  home.     In  a  fortnight  all  the  symptoms  reappeared  more  severe  than  before. 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  583 

He  went  away  again  to  Southsea,  and  there  used  salt-water  baths,  when  he  a  second 
time  rapidly  improved,  and  at  the  end  of  a  month  returned  home.  Shortly  afterwards, 
however,  the  old  symptoms  reappeared,  when  he  was  advised  to  consult  a  London  phy- 
sician. He  was  ordered  to  use  galvanism  in  the  form,  he  stated,  of  magneto- electric 
shocks,  which  did  not  benefit  him,  when  his  doctor,  suspecting  lead,  had  his  drinking- 
water  analyzed  and  found  it  to  be  strongly  impregnated  by  lead.  He  was  then,  of  course, 
put  on  a  proper  course  of  medicine,  desisted  from  the  use  of  water,  and  he  improved. 
He  had  continued  the  use  of  the  galvanism.  He  subsequently  left  London  and  again 
went  to  Southsea. 

When  I  saw  him,  in  March,  he  had  got  into  a  stationary  condition  and  was  in  the  state 
above  described— his  limbs  wasted  and  with  little  power  in  them.  I  ordered  him  some  • 
small  doses  of  iodide  of  potassium  and  quinine,  and  wished  him  to  use  a  simple  galvanic 
current  rather  than  electro  magnetism.  Finding  there  would  be  a  difficulty  in  making 
use  of  this  at  his  own  house,  I  advised  him  to  go  to  Guy's  Hospital  every  morning,  and 
to  this  he  readily  assented. 

Mr.  Sandy,  the  electrician,  tried  the  effects  of  the  continuous  battery-current  upon  him, 
and  also  the  induced  current,  with  the  following  results  :  In  the  right  arm  the  extensor 
muscles  contracted  well  by  the  application  of  twenty  cells  of  the  Daniell's  battery.  The 
induced  current  was  applied,  as  strong  as  the  patient  could  bear,  with  scarcely  any  con- 
traction. In  the  left  arm  the  muscles  contracted  well  by  fifteen  cells  and  with  precisely 
the  same  results  on  the  right  arm,  with  the  induced  or  interrupted  current.  In  the  legs 
twenty  cells  caused  good  contraction,  but  scarcely  any  result  was  obtained  by  the  inter- 
rupted current. 

He  continued  the  use  of  the  galvanism  to  the  limbs  daily,  and  made  visible  progress. 
On  April  i8th  he  had  considerably  more  power  of  the  limbs  than  he  had  a  month  pre- 
viously, and,  on  the  muscles  being  tested,  it  was  found  that  the  "induced"  current, 
which  had  been  powerless  before,  now  excited  the  extensor  muscles  of  the  right  arm,  so 
that  the  hand  was  raised  on  a  level  with  the  arm.  On  application  of  the  same  strength 
to  the  left  arm  it  extended  the  fingers  much  more  than  the  right,  but  the  hand  was  not 
lifted  to  the  same  extent. 

The  patient  persisted  in  the  treatment  up  to  July,  during  this  period  gradually  improv- 
ing, and  in  August  he  had  quite  recovered  the  use  of  his  hands  and  was  following  his 
usual  occupation. 

Case  4.  Lead  Para/j/jw.— Margaret  C,  set.  47,  admitted  February  29th,  1872.  She 
has  been  married  and  has  a  large  family.  Two  years  ago  her  husband  died,  when  she 
was  obliged  to  work  for  her  living.  She  gained  employment  in  some  lead  mills,  her 
business  being  to  grind  the  white  lead.  For  some  months  past  she  has  been  getting  thin 
and  feeble,  her  arms  wasted,  together  with  stiffness  and  pain  in  the  shoulders.  Has  had 
slight  colic. 

071  admission  :  She  seems  to  be  a  small,  spare  woman,  ansemic  and  sallow — looking, 
indeed,  extremely  ill.  She  is  thin,  owing  to  a  general  wasting  of  the  muscles  of  the 
whole  body — more  in  the  extremities,  and  especially  in  the  arms.  She  is  too  feeble  to 
walk,  and  therefore  obliged  to  keep  her  bed .  She  can  scarcely  raise  her  arms  from  her 
side,  owing  to  the  atrophy  and  weakness  of  the  muscles.  The  extensor  muscles  of  fore- 
arm are  extremely  wasted,  rendering  the  arm  quite  flat ;  the  wrists  drop  down  without 
there  being  the  slightest  power  to  raise  them.  Muscles  of  hand  soft  and  flabby,  the  right 
arm  and  hand  worse  than  the  left,  so  that  she  cannot  use  them  for  feeding  herself.  The 
blue  line  on  the  gums  well  marked,  and  a  distinct  blue  stain  along  the  lower  lip  corre- 
sponding to  the  stained  border  of  the  gums.  Slight  oedema  of  eyelids.  Ordered  ten 
grains  of  iodide  of  potassium  three  times  a  day.     Tested  by  galvanism.     Faradization : 


584  PSYCHOLOGICAL   MEDICINE. 

As  much  power  as  the  patient  can  bear  has  a  very  slight  effect  upon  the  extensors  of  the 
thumb  and  not  upon  the  other  muscles.  Continuous  battery-current :  Good  and  well- 
marked  contraction  of  all  the  extensors  by  twenty  Daniell's  cells.  The  continuous  cur- 
rent ordered.  Mr.  Sandy  finds  the  more  efficient  method  to  be  by  placing  the  fingers  in 
water  containing  a  little  salt;  the  negative  pole  is  placed  in  the  water  and  the  positive 
pole  gently  stroked  along  the  extensors.  This  causes  contraction  of  the  muscles  and  ele- 
vation of  the  wrist.     When  the  poles  are  reversed  the  current  and  the  effect  are  less. 

April  17th.  The  continuous  current  has  been  used  to  the  limb  daily  up  to  the  present 
time,  and  the  improvement  has  been  marked,  though  gradual.  The  blue  line  on  the 
gums  is  much  less.  She  is  out  of  bed  to-day  for  the  first  time.  As  the  improvement  has 
been  going  on,  so  the  muscles  have  become  susceptible  to  faradization,  whereas  they  have 
required  a  larger  amount  of  simple  galvanism  to  affect  them. 

May  13th.  Improved  considerably;  walks  about.  Is  able  to  feed  and  dress  herself. 
Can  extend  the  wrist,  and  the  arms  are  larger  in  bulk.  Blue  lines  on  gums  and  lips  dis- 
appearing. On  testing  with  faradization  there  is  marked  contraction  in  the  extensors,  the 
hands  being  well  lifted ;  this  is  more  so  in  the  left  arm  than  the  right,  the  right  being 
always  weaker  and  smaller. 

In  this  case  it  may  be  remarked  that  besides  a  well-marked  blue  line  along  the  edge  of 
the  lower  gums  there  was  a  dark  patch  on  the  mucous  membrane  of  the  under  lip,  corre- 
sponding in  position  to  that  on  the  gums,  but  rather  more  defined  and  dotted.  A  ques- 
tion is  always  asked  in  the  wards  whether  this  mark  on  the  lip  is  formed  independently 
or  follows  that  on  the  gums  from  contact.     The  latter  is  the  probable  explanation. 

In  these  cases  of  dropped  wrist  the  back  of  the  hand  is  often  obser\'ed  to  be  rounded, 
apparently  from  enlargement  of  the  metacarpal  bones,"  but  due  in  all  probability  to  some 
thickening  of  the  thecK. 

Case  5.  Phanbism  treated  7vith  Electric  Bath. — William  J-,  Kt.  36,  admitted  under  Dr. 
Wilks,  July  17th,  and  left  July  27th.  He  began  to  Avork  at  grinding  lead  nine  months 
ago,  and  at  the  end  of  about  five  months  commenced  to  feel  ill,  with  loss  of  appetite, 
pains  in  his  head  and  abdomen,  and  general  debility.  He  continued  at  his  work  and 
daily  grew  worse,  until  a  week  ago,  when  he  was  obliged  to  desist,  having  pains  in  his 
limbs,  sweating  and  inability  to  stand,  and  vomiting. 

On  admission  :  He  was  seen  to  be  very  pale  and  very  thin,  having  evidently  lost  a 
great  deal  of  flesh.  Skin  hot,  tongue  furred,  marked  blue  lines  on  gums.  Constipation. 
Recti  abdominis  contracted  and  painful. 

July  20th.  Ordered  an  electric  bath.  This  was  made  by  Mr.  Sandy,  as  follows  :  The 
bath  being  prepared,  enough  sulphuric  acid  was  put  into  it  to  give  it  a  slight  acid  taste 
(about  giv) ;  the  negative  pole  of  the  battery,  attached  to  a  large  sheet  of  copper,  about 
two  and  a  half  feet  square,  was  put  upright  in  the  bath,  and  the  patient  placed  in  it  so  as 
not  to  touch  the  copper  plate  ;  the  hand  of  the  patient  was  held  out  of  the  water,  and  in 
it  he  held  the  positive  pole.  Fifty  and  eighty  cells  were  tried,  but  when  the  cun-ent  was 
applied  to  the  neck  instead  of  the  hand,  the  patient  could  not  bear  more  than  fifty  cells. 
On  making  and  breaking  contact  the  patient  felt  a  kind  of  thud  through  the  whole  of  the 
body.     A  bath  lined  with  glazed  tiles  was  used. 

The  patient  used  the  bath  again  on  the  24th,  and  a  third  time  on  the  25th.  He  said  he 
felt  very  cold  after  it.  He  always  had  his  bowels  relieved  immediately  after  it.  On  each 
occasion  he  felt  better,  and  on  the  27th  he  was  so  much  improved  that  he  went  out. — 
Guy' s  Hospital  Reports,  vol.  xviii.,  1873,  p.  14S. 

On  the  influence  of  the  continuous  galvanic  current  over  voluntary 
muscular  action,  Dr.  G.  V.  Poore,  Assistant  Physician  to  Charing 
Cross  Hospital,  says  : 


ELECTRICITY   IN    DISEASES    OF   THE    NERVOUS   SYSTEM.  585 

In  the  number  of  the  Practitiotter  for  September  last  will  be  found  a  paper  by  the  writer 
on  a  case  of  "  Writer's  Cramp  and  General  Spasm  of  the  Right  Arm,"  which,  though  of 
nine  years'  standing,  was  successfully  treated  by  the  joint  use  of  the  continuous  galvanic 
current,  and  the  rhythmical  exercise  of  the  affected  muscles.  For  the  benefit  of  those 
who  may  not  have  read  that  paper,  I  may  be  allowed  to  say  that  the  method  of  treatment 
was  as  follows :  A  continuous  current  was  passed  through  a  single  muscle  (such  as  the 
deltoid),  or  a  group  of  muscles  (such  as  the  flexors  of  the  wrist  and  hand)  ;  and  while 
the  muscles  were  under  the  influence  of  the  current,  the  patient  was  ordered  to  exercise 
them  voluntarily.  This  method  of  treatment  was  followed  by  the  best  results — results 
which  were  surprising  to  myself  and  my  medical  friends. 

At  that  time  I  offered  no  explanation  as  to  why  this  method  of  employing  galvanism 
proved  so  serviceable.  I  was  inclined  to  regard  the  galvanism  as  of  use  merely  in  over- 
coming muscular  spasm,  and  attributed  to  the  rhythmical  exercises  most  of  the  perma- 
nent improvement  which  took  place.  Since  then  I  have  had  further  experience  of  this 
method  of  employing  galvanism,  and  havfe  obtained  some  insight  into  the  modus  operandi 
of  the  continuous  current  when  thus  employed. 

One  of  the  usually  prominent  symptoms  in  writer's  cramp  or  palsy  is  a  feeling  (more 
or  less  intense  and  more  or  less  unbearable)  of  fatigue  along  the  muscles  of  the  arm. 
This  may  be  limited  to  the  forearm,  or  may  extend  from  the  shoulder  to  the  tips  of  the 
fingers.  I  have  found  that  this  feeling  of  fatigue  is  at  once  removed  by  the  application 
of  the  continuous  galvanic  current,  either  along  the  course  of  the  nerves  or  the  muscles 
of  the  arm.  One  patient,  who  has  suffered  very  acutely  from  this  feeling  of  fatigue,  has 
always  expressed  great  satisfaction  during  the  employment  of  the  current,  and  has  fre- 
quently used  the  words  "  comfortable,"  and  "  pleasant,"  to  express  his  sensations.  He  has 
also  often  said,  "  That  seems  to  give  7ne  strength,  to  give  me  a  sense  of  power  in  the  arm.^'' 
This  patient  also  had  a  difficulty  in  supinating  the  hand  of  the  right  arm.  There  was  no 
true  paralysis,  and  no  visible  wasting  of  any  of  the  muscles  (though  the  whole  of  the  arm 
and  forearm  was  notably  flabby,  and  remarkably  non-muscular)  but  the  act  of  supina- 
tion was  a  labored  act,  and  the  patient  soon  tired  of  performing  it. 

On  telling  him  to  alternately  pronate  and  supinate  the  hand,  these  acts  were  accom- 
plished tolerably  well  for  the  first  four  times,  then  the  act  of  supination  became  slow,  and 
was  accomplished  with  an  evident  effort,  and  after  four  or  five  more  attempts  it  became 
impossible  ;  and  this,  as  far  as  one  could  see,  was  not  due  to  any  spasm  of  antagonizing 
muscles.  When  the  supination  came  to  a  standstill,  I  placed  the  positive  sponge-holder 
of  my  battery  as  near  as  possible  over  the  spot  where  the  musculo-spiral  nerve  turns 
forward  at  the  outer  part  of  the  elbow-joint,  and  the  negative  on  the  spot  where  the  radial 
nerve  becomes  superficial  on  the  radial  border  of  the  forearm.  The  number  ofelements 
employed  was  sufficient  to  cause  an  appreciable  but  not  painful  sensation  to  the  patient. 
This  seemed  to  help  the  supinators  over  their  difficulty,  and  the  patient  continued  to  pro- 
nate and  supinate  his  hand  without  the  least  trouble,  telling  me  at  the  time  that  "  he 
could  do  it  much  easier  when  I  passed  the  current,"  and  also  "  that  it  seemed  to  give  him 
strength.''''  Other  muscular  exercises  were  practised  with  this  patient,  such  as  repeated 
flexings  and  extendings  of  the  fingers,  or  of  the  thumb  alone,  and  he  always  said  that  the 
movements  were  accomplished  more  easily,  and  he  got  less  readily  fatigued  when  a  gal- 
vanic current  was  passed  through  the  muscles  implicated,  or  along  the  nerve  supplying 
them.  "It  seems,"  he  said,  "  to  give  me  strength  and  power."  One  is  not  inclined,  at 
least  I  am  not,  to  pay  much  attention  to  the  sensations  and  expressions  of  a  patient ;  and 
although  my  patient  was  an  intelligent  man,  I  thought  nothing  of  what  he  said  until  I 
found  another  (also  suffering  from  writer's  cramp)  who  said  precisely  the  same  thing, 
"  that  he  could  accomplish  repeated  muscular  acts  with  far  greater  ease  during  the  passing 


586  PSYCHOLOGICAL    MEDICINE. 

of  a  current,  and  that  after  the  employment  of  the  current  he  had  a  feeling  of  strength 
and  power  in  the  arm."  This  latter  patient's  expression  demanded  attention,  for  he  was 
a  medical  man,  and  himself  accustomed  to  the  employment  of  electricity.  This  gentle- 
man suffered  acutely  from  the  miserable  feeling  of  fatigue  in  his  arm ;  and  though  his 
muscles  are  big,  and  he  is  decidedly  athletic,  he  soon  tires  of  repeated  exercises.  This 
tiring  of  the  muscles  and  the  feeling  of  fatigue  were  both  obviated  by  the  employment  of 
the  current. 

From  these  disjointed  observations  I  got  the  idea  that  the  passage  of  the  continuous 
current  through  muscles,  or  the  nerves  supplying  them,  increases  the  susceptibility  of 
those  muscles  to  the  stimulus  of  the  will,  and  that  their  voluntary  power  is  thereby 
greatly  increased. 

I  proceeded  to  submit  this  notion  to  the  test  of  experiment,  and  nearly  every  experi- 
ment I  have  made  goes  to  prove  the  correctness  of  my  theory. 

The  first  experiment  was  made  upon  the  patient  (H.  M.)  first  mentioned  in  this  paper. 
I  asked  him  to  hold  his  left  arm  at  right  angles*  to  his  body,  and  in  the  palm  of  the  hand 
I  placed  a  weight  of  seventeen  ounces.  "  Now,"  said  I,  "  tell  me  when  you  begin  to 
feel  tired,  and  that  you  can  go  on  no  longer."  In  about  four  minutes  (the  experiment 
was  only  tentative  and  not  exact)  he  complained  of  great  pain  in  his  muscles, — deltoid,  tri- 
ceps, biceps,  and  forearm, — and  declared  his  inability  to  go  on.  I  then  placed  the  posi- 
tive rheophore  high  up  in  the  axilla,  and  applied  the  negative  one  to  the  painful  parts, 
when  he  at  once  said,  "  All  the  fatigue  is  gone,  and  I  feel  as  strong  as  when  I  began." 
On  the  evening  of  the  same  day  a  scientific  friend  kindly  submitted  himself  to  a  similar 
experiment,  and  the  result  was  the  same.  When  the  sponges  were  applied,  he  said,  "All 
the  fatigue  is  gene;  I  feel  just  as  though  some  one  had  given  my  hand  a  support."  I 
need  hardly  say  that  great  care  was  taken  not  in  any  way  to  support  the  limb  with  the 
rheophores ;  in  fact,  in  these  experiments  one  of  the  rheophores  at  all  events  has  gene- 
rally been  as  an  additional  burden  to  the  arm.  The  current  employed  has  hardly  ever 
been  strong  enough  to  produce  involuntary  contraction  of  the  muscles.  My  next  experi- 
ment was  made  on  a  student  of  medicine,  Mr.  L.  S.  The  result  was  exactly  similar. 
At  the  end  of  seventy  seconds  he  began  to  make  complaints  of  pain  and  fatigue,  which 
the  current  at  once  removed,  and  he  continued  to  support  the  weight  for  five  minutes 
and  a  quarter,  declaring  at  the  end  that  if  I  wished  he  still  could  go  on,  which  I  would 
not  allow.  This  was  the  right  hand.  We  then  tried  the  left  hand,  without  employing 
any  current  at  all  He  broke  down  in  considerable  pain  after  holding  the  weight  for 
two  minutes  and  a  quarter.  In  the  evening  of  the  same  day  he  stated  that  his  left  hand 
had  been  aching  all  day,  but  that  the  right  had  not  given  him  any  trouble.  Two  days 
later  he  tried  the  right  arm  again,  but  without  using  the  current.  He  managed  with  the 
greatest  difficulty  to  support  the  weight  for  three  minutes  and  ten  seconds,  and  the  effort 
was  followed  by  considerable  aching  and  pain.  On  December  6th  I  asked  my  patient 
H.  M.  to  hold  the  weight  in  his  left  hand,  and  on  this  occasion  no  electricity  was  used. 
He  is  a  man  whose  power  of  endurance  is  very  great,  and  he  managed  to  sustain  the 
weight  for  six  minutes,  but  endured  considerable  pain  and  fatigue  while  doing  so.  On 
December  7th  I  first  galvanized  the  arm,  and  then  got  him  to  repeat  the  experiment,  and 
while  the  experiment  was  in  progress  I  occasionally  passed  a  current  down  the  arm  and 
through  those  muscles  in  which  any  sense  of  fatigue  or  pain  was  developed.  On  this  oc- 
casion he  managed  to  sustain  the  weight_/br  thirteen  7ninutes  and  a  half,  a  time  which  I 
should  think  few,  if  any,  men  could  accomplish  without  aid. 

Similar  experiments  to  these  have  been  tried  on  several  of  my  friends,  and  they  all 
tend  to  show  that  the  endurance  of  voluntary  muscular  action  is  enormously  increased  by 
the  passage  of  a  continuous  current,  and  that  the  feeling  of  fatigue,  both  during  and  after 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  58/ 

the  prolonged  effort,  is  mitigated  or  entirely  obviated.  It  may  be  that  the  first  result  is 
merely  a  consequence  of  the  second. 

Experiments  have  also  been  made,  and  with  results  which  tend  to  show  that  the  force, 
as  well  as  the  endurance,  of  voluntary  muscular  action  is  increased  by  employing  a  gal- 
vanic current.  The  muscles  experimented  upon  have  been  the  flexors  of  the  fingers,  the 
contracting  force  of  the  muscles  being  registered  by  the  squeezing  of  a  spring  dynamom- 
eter held  in  the  hand. 

The  majority  of  my  experiments,  typical  samples  of  which  I  have  alone  given,  tend 
with  greater  or  less  force  to  show  that  the  force  and  endurance  of  voluntary  muscular 
action  are  both  increased  by  the  passing  of  a  galvanic  current  through  the  nerves  or  mus- 
cles implicated;  but  as  I  have  above  stated,  it  is  exceedingly  difficult  to  get  constant  re- 
sults with  the  spring  dynamometer,  and  although  my  experiments  with  this  instrument  all 
tend  one  way,  I  do  not  regard  the  results  as  final. 

The  therapeutic  importance  of  this  fact  is,  I  think,  considerable,  and  is  likely  to  lead 
to  the  combined  use  of  electricity  and  voluntary  movements  in  many  diseases  where  there 
is  only  partial  impairment  of  muscular  power.  The  case  which  I  published  in  Septem- 
ber is  only  a  solitary  example  of  the  benefits  of  this  method  of  treatment,  and  is  conse- 
quently of  little  value.  I  may  mention,  however,  that  I  have  two  similar  cases  novV 
under  my  care  which  are  being  treated  in  the  same  way,  and  are  making  rapid  progress. 
It  seems  to  me  better,  in  all  cases  where  it  is  possible,  to  let  a  muscle  react  to  its  proper 
stimulus, — the'  will, — than  to  employ  for  the  purpose  of  causing  muscular  contraction  a 
stimulus  which  is  wholly  artificial  I  should  mention  that  the  effect  of  the  galvanic  cur- 
rent seems  to  endure  for  some  time  after  its  discontinuance  ;  how  long  we  cannot  say  ; 
but  my  patients,  if  this  is  worth  anything,  tell  me  that  their  arms  retain  the  feeling  of 
power  and  strength  for  about  an  hour.  I  am  hoping  to  be  able  to  make  further  experi- 
ments on  the  effect  of  a  galvanic  current  upon  common  sensation. 

Some  cases  illustrating  the  employment  of  central  galvanization  in 
various  sensory  disturbances  are  given  by  Dr.  Thomas  Buzzard, 
Physician  to  the  National  Hospital  for  the  Paralyzed  and  Epileptic 
in  England.     He  says  : 

The  influence  of  the  constant  galvanic  current  in  relieving  pain,  and  often  permanently 
arresting  it,  in  the  district  of  a  single  nerve  or  the  distribution  of  a  plexus,  is  by  this 
time  well  established,  although  the  conditions  which  affect  its  success  or  failure  must  be 
allowed  to  be  still  undetermined.  I  have  been  trying  central  galvanization  lately  in  a 
number  of  anomalous  conditions  of  the  sensory  organs,  as  well  as  in  cases  of  well- 
marked  neuralgia,  with  a  varying  result.  Out  of  these  cases  I  propose  to  cull  a  few 
which  appear  the  most  interesting,  or  about  which  I  am  in  a  position  to  give  the  most 
accurate  information. 

Case  i. — A  man,  aged  68,  had  suffered  for  one  year  from  pain,  limited  to  the  region  of 
the  two  upper  divisions  of  the  fifth  nerve,  left  side.  The  pain  was  constant,  but  terribly 
increased  besides  by  moving  in  walking,  or  even  driving,  or  by  a  current  of  air.  There 
was  also  such  intense  hypersesthesia  of  the  skin  that  he  could  bear  nothing  to  touch  this 
side  of  his  face,  which  was  consequently  left  unwashed  and  very  dirty.  He  could  not 
even  bear  the  bedclothes  upon  it. 

The  constant  current  from  five  cells  Daniell-Muirhead — the  negative  pole  to  the  painful 
region,  and  the  positive  to  the  nape  of  the  neck — was  applied  once  during  three  minutes. 
He  was  then  from  circumstances  unable  to  attend  the  hospital  for  three  months,  when 


588  PSYCHOLOGICAL    MEDICINE. 

he  appeared-  again,  still  suffering  as  described.  The  current  was  now  applied  regularly 
twice  a  day  in  the  manner  just  noted,  with  a  gradual  improvement.  After  six  weeks  the 
pain  had  ceased  to  be  constant,  although  it  still  attacked  him  at  intervals,  but  the  hyper- 
sesthesia  of  the  skin  was  entirely  cured.  I  could  touch  roughly  any  part  of  the  affected 
region. 

I  would  just  add  here,  that  although  I  have  not  found  any  marked  benefit  from  gal- 
vanism in  ordinary  toothache,  yet  for  the  scarcely  less  wearisome  aching  which  remains, 
often  for  hours,  after  the  extraction  of  a  tooth,  the  constant  current  is  of  extraordinary 
value.     It  will  generally  stop  this  effectually  at  once. 

Case  2. — A  single  woman,  aged  42,  who  had  been  epileptic  from  17  to  35  years  of  age, 
coupled  with  violent  pain  in  both  parietal  regions,  occasional  loss  of  memory,  and  fears 
about  retaining  her  reason.  There  was  a  history  of  struma  in  early  life,  and  later  a  good 
deal  of  mental  trouble.  K.  Br.  was  useful  at  first,  and  then  failed  to  relieve  her,  as  did 
opiates  and  chloride  of  ammonium.  The  pain  was  intense,  coupled  with  vertigo,  tinnitus 
aurium,  flushing  of  face,  besides  occasional  stammering  and  subjective  sensation  of 
"  people  talking."  She  then  had  the  constant  current  from  eight  cells  Stohrer  through 
the  temples,  and  also  with  the  positive  pole  on  the  neck,  the  negative  on  the  painful  part, 
two  minutes  in  each  direction. 

During  the  application  the  pain  left  her.  Three  times  in  each  week  this  treatment, 
without  drugs,  was  continued  for  six  weeks.  Sometimes  the  pain  would  return  as  soon 
as  she  had  quitted  the  electrical  room,  at  others  it  would  relieve  her  for  a  few  hours.  On 
the  whole,  however,  she  improved ;  her  memory  was  clearer,  she  lost  some  of  her  dis- 
comforts, and  became  more  cheerful.  But  this  did  not  last,  and  at  the  end  of  this  time 
it  was  pretty  evident  that  she  was  in  veiy  much  the  same  state  as  at  first.  I  therefore 
stopped  the  galvanism  and  gave  her  arsenic,  which  immediately  relieved  her  much  more 
than  anything  which  had  been  done. 

These  were  cases  of  neuralgia. 

Case  7. — A  single  woman,  aged  29,  had  suffered,  at  the  time  of  her  application  at  the 
hospital,  for  two  and  a  half  years,  from  severe  pain  in  the  head,  as  often  on  one  side  as 
on  the  other.  Her  appearance  was  striking  from  the  hair  of  her  head  being  throughout 
completely  gray,  the  change  in  color  having  commenced  when  she  was  seventeen  years  of 
age.  She  had,  as  might  have  been  expected,  a  neurotic  family  history,  which  is  worth 
giving  in  detail.  One  of  her  sisters,  it  seems,  turned  gray  at  twenty-one  and  died  at  forty- 
seven  of  "  epilepsy."  Another  sister  died  between  thirty  and  forty  years  of  age  of  con- 
sumption, and  "  her  mouth,"  the  patient  said,  "  was  drawn  to  one  side."  A  third  sister  is 
still  living,  thirty-four  years  of  age,  and  not  at  all  gray.  Six  of  her  brothers  died  in  child- 
hood— one  suddenly  at  seven  years  of  age,  one  soon  after  birth,  and  the  others  either  of 
zymotic  diseases  or  from  some  cause  which  she  could  not  remember.  Her  mother,  still 
living,  seventy-six  years  of  age,  suffered  during  the  last  two  winters  from  neuralgia. 
Her  father  died  of  dropsy,  after  rheumatic  gout  and  drinking. 

She  herself  was  in  good  health  till  four  or  five  years  ago,  when  she  became  sub- 
ject to  violent  headache,  which  for  the  last  two  and  a  half  years  had  never  entirely  left 
her. 

The  occipito-parietal  region  of  the  head  was  indicated  as  the  chief  seat  of  the  pain, 
which  attacked  sometimes  one  side  and  sometimes  the  other,  and  the  corresponding  arm 
was  described  as  feeling  numb  and  wanting  power  during  the  exacerbations.  Digital 
pressure  upon  the  occipital  bone  and  in  the  neighborhood  of  each  parietal  eminence  made 
her  flinch  very  much.     There  was  nothing  in  her  other  organs  to  call  for  remark. 

Chloride  of  ammonium,  iron  and  quinine  were  severally  administered  without  good 
result,  but  were  often  vomited.     Chloroform  and  belladonna  were  also  applied  locally 


ELECTRICITY    IN    DISEASES    OF    THE   NERVOUS   SYSTEM.  589 

without  relief.  For  three  weeks  she  was  injected  subcutaneously  with  morphia  (j/^ 
grain),  and  with  considerable  temporary  relief,  the  effect  lasting  more  or  less  for  twenty- 
four  hours.  The  injection  made  her  quite  stupid  for  several  hours,  and  she  slept  well 
during  the  night  following,  her  ordinary  habit  being  to  be  awakened  repeatedly  by  the  pain. 
Altogether,  she  said  she  had  never  been  so  easy  as  under  this  treatment. 

The  constant  current,  derived  from  twenty  to  twenty-five  cells  of  Daniell-Muirhead 
battery,  was  then  employed,  the  positive  rheophore  being  applied  to  the  nape  of  the  neck, 
and  the  negative  to  the  tender  points  in  turn,  the  application  to  each  lasting  two  minutes. 
Then  a  rheophore  being  placed  on  each  temple,  a  current  of  like  strength  was  passed 
for  two  minutes.  This  treatment  was  continued  three  times  a  week  for  three  weeks. 
The  patient  reported  that  during  the  application  of  the  current  she  entirely  ceased  to 
feel  the  pain,  and  that  generally  for  two  or  three  hours  afterwards  there  was  considerable 
ease.  The  alleviation,  however,  did  not  last  nearly  so  long  as  that  produced  by  the 
morphia  injection.  A  trial  was  then  made  of  a  proceeding  which  is  termed  galvaniza- 
tion of  the  sympathetic.  One  of  the  rheophores  (a  small  metallic  disk  covered  with 
wetted  leather)  was  held  firmly  in  the  right  auriculo-maxillary  fossa,  and  the  other  ap- 
plied to  the  side  of  the  lower  cervical  vertebrae,  and  a  current  from  fifteen  cells  of  Daniell- 
Muirhead  battery  allowed  to  pass  during  five  minutes.  This  treatment  has  now  been 
continued  for  ten  weeks,  the  current  being  tlius  applied  from  three  to  six  times  a  week. 
She  says  that  during  its  application  she  feels  very  bad,  and  as  if  she  were  going  to  die, 
the  sensation  being  very  much  worse  than  that  produced  by  the  other  electrical  treat- 
ment. The  giddiness  persists  for  half  an  hour,  but  there  is  no  faintness.  The  resulting 
ease,  however,  lasts  far  longer  than  that  which  followed  the  former  process,  often  continu- 
ing until  the  next  day.  At  times  she  has  been  a  good  deal  better,  and  altogether  it  is 
certain  that  she  has  not  had  such  violent  attacks  as  formerly.  On  the  other  hand,  she 
cannot  think  the  relief  is  permanent,  for  if  she  goes  a  little  longer  than  usual  without  the 
treatment,  the  pain  becomes  severe.  I  have  now  ordered  the  application  to  be  used  to 
each  side  of  the  neck  in  turn  at  every  silting. 

The  process  of  galvanization  just  described,  it  is  right  to  mention,  is  sometimes  at- 
tended with  more  unpleasant  results  than  those  which  this  woman  described.  Some 
years  ago  I  -was  attending  a  gentleman,  aged  forty-six,  who  suffered  from  epileptoid  at- 
tacks and  a  variety  of  nervous  sensations.  On  one  occasion  I  applied  this  process  to 
him,  employing,  however,  a  much  more  feeble  current — that  derived  from  five  cells  of 
Foveaux's  battery.  I  noted  before  commencing  that  his  pulse  numbered  78,  and  was 
steady  and  good.  He  described  himself  as  feeling  better  than  usual.  The  application 
had  only  been  continued  during  two  minutes,  when  he  changed  countenance,  complained 
of  feeling  faint,  of  a  tightness  about  the  brain,  difiiculty  of  breathing,  and  a  feeling  of  sick- 
ness. There  was  an  imitation  in  fact  of  the  feeling  which  preceded  his  attacks.  I  ob- 
served that  his  pulse  had  lost  force  and  beat  more  slowly,  that  his  face  was  pale,  and  his 
pupils  widely  dilated.  "With  the  aid  of  a  stimulant  he  gradually  revived  sufficiently  to 
leave  my  house.     He  did  not  come  again. 

I  think  it  is  difficult  to  feel  convinced  as  yet  that  the  process  described  is  really  a  gal- 
vanization of  the  sympathetic.  It  must  be  remembered  that  the  rheophore,  when  planted 
in  the  auriculo-maxillary  fossa,  is  in  the  immediate  neighborhood  of  several  important 
nerves,  and,  indeed,  is  nearer  to  them  than  to  the  superior  cervical  ganglion.  That  there 
is  always  a  considerable  diffusion  of  electricity  from  the  spot  to  which  a  rheophore  is  ap- 
plied, there  can  be  no  doubt.  I  have  frequently  observed,  for  example,  that  in  attempt- 
ing to  galvanize  the  anterior  tibial  muscles  of  the  leg  in  a  case  of  infantile  paralysis,  the 
current  has  been  conveyed  to  the  muscles  of  the  calf  or  the  outside  of  the  leg,  and  caused 
them  to  contract.     It  is  impossible  to  conceive,  therefore,  that  the  numerous  nerves 


590  PSYCHOLOGICAL   MEDICINE, 

•which  are  to  be  found  just  below  and  about  the  temporo-maxillarj''  articulation  can  es- 
cape at  least  some  of  the  influence  of  the  current  when  applied  to  this  region.  The  im- 
portant experiments  of  Brown-Sequard  have  shown  us  that  galvanization  of  the  sympa- 
thetic in  the  neck  causes  contraction  in  the  walls  of  the  arteries  supplied  -by  its  branches. 
Now,  branches  from  the  superior  cervical  ganglion  proceed  to  the  internal  carotid,  form- 
ing the  carotid  and  cavernous  plexuses  and  following  the  vessels  as  they  branch  to  their 
distribution.  One  of  these  ultimate  branches,  the.  central  artery  of  the  retina,  is,  thanks 
to  the  ophthalmoscope,  within  our  ken.  If  the  process  described  be  a  true  galvanization 
of  the  sympathetic,  we  might  expect  to  see,  during  its  application,  some  alteration  in  the 
size  or  color  of  this  branch.  On  one  occasion  I  got  Dr.  Tibbits,  our  electrician,  to  apply 
the  process  to  the  woman  whose  case  I  have  above  related,  whilst  I  carefully  watched 
the  fundus  oculi  of  the  same  side  with  the  ophthalmoscope,  employing  the  direct  image 
as  being  the  largest,  and  in  all  respects  the  most  favorable,  for  this  observation.  The 
woman  had  a  large  pupil,  and  the  view  obtained  was  exceedingly  distinct.  There  was 
certainly  no  change  whatever  to  be  observed  in  the  size  or  color  of  the  artery  during  the 
passage  of  the  current,  nor  after  its  withdrawal.  In  the  case  last  described  it  therefore 
seems  at  least  as  likely,  I  think,  that  the  unpleasant  effects  upon  the  patient  were  pro- 
duced by  accidental  galvanization  of  the  pneumogastric  as  that  the  sympathetic  ganglion 
was  acted  upon.  It  will  be  remembered  that  in  1846  it  was  shown  by  the  brothers 
Weber  that  galvanization  of  the  pneumogastric  in  the  neck  caused  the  pulsations  of  the 
heart  to  become  slower,  and,  if  applied  in  sufficient  strength,  arrested  its  action  altogether. 
So  aofain,  it  is  conceivable  that  in  the  woman's  case  the  relief  she  experiences  may  be 
owing  to  galvanization  of  the  auriculo-temporal  nerve,  and  possibly  a  thence  reflected  in- 
fluence upon  other  branches  of  the  fifth,  for  the  rheophore  is  at  least  as  near  to  this  trunk 
as  to  the  superior  cervical  ganglion. 

Respecting  the  relations  of  faradic  electricity  to  pain,  Dr.  Francis 
E.  Anstie,  Editor  of  the  Practitioner,  says  : 

One  of  the  most  important  uses  of  electricity  is  certainly  the  relief  of  pain.  And  as 
pain  is  so  common,  and  often  so  troublesome  a  thing  to  deal  with,  it  is  natural  that  prac- 
titioners should  eagerly  seize  hold  of  what  promises  to  be  a  new  mode  of  relicNang  it, 
without  inquiring  very  minutely  as  to  the  precise  conditions  under  which  success  is  most 
likelv  to  be  obtained.  The  outcome  of  this  indiscriminate  employment  of  the  remedy 
can  only  be  vexatious  disappointment  in  a  number  of  cases,  and,  in  some,  a  positive 
aggravation  of  the  suff'erings  of  the  patient. 

It  is  time  for  every  one  to  understand  that,  in  regard  to  the  treatment  of  painful  affec- 
tions, faradization  has  very  distinct  and  rather  narrow  boundaries  of  usefulness,  and  these 
it  is  now  our  business  to  define. 

I.  Faradization  is,  in  the  first  place,  pre-eminently  useful  as  a  mental  counter-irritant 
(if  we  may  use  the  phrase),  and  therefore  will  often  cure  pains  of  the  class  vaguely  called 
"  hvsterical."  In  the  relaxed  condition  of  the  nervous  tone  which  belongs  to  this  state, 
the  mere  accidental  concentration  of  attention  on  a  particular  part  of  the  body  will  often 
convert  some  slightly  unusual  sensations  into  the  mental  perception  of  actual  pain ;  but 
this  perception  is  factitious,  and  can  be  speedily  destroyed  by  a  suitable  diversion.  For 
this  purpose  smart  and  painful  faradization  of  the  skin  is  well  adapted,  and  it  should  be 
applied  to  a  somewhat  larger  area  than  that  which  the  hysterical  pain  occupies.  The 
surface  being  carefully  dried  (and,  if  necessary,  powdered),  in  order  to  limit  the  effects 
as  much  as  possible  to  the  skin,  the  current  is  applied  with  dry  metal  or  carbon  elec- 
trodes, one  pole  being  placed  on  an  indifferent  spot,  the  other  moved  slowly  about  over 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  59 1 

the  area  which  we  mean  to  operate  upon.  The  result  is,  that  the  mental  attention  is  so 
scattered  and  divided  among  a  number  of  new  and  sharp  impressions,  that  its  morbid 
concentration  is  lost,  and  the  sensation  of  pain  disappears.  It  is  very  necessary,  in  the 
early  stages  of  such  cases,  to  have  the  electrical  apparatus  at  hand,  so  that  any  relapse 
into  the  state  of  actual  pain  may  be  promptly  dealt  with. 

2.  The  pains  we  have  just  been  speaking  of  are  mainly  of  a  pseudo-neuralgic  char- 
acter; that  is  to  say,  they  run  so  far  in  the  direction  (or  the  neighborhood)  of  recog- 
nizable nerves  as  to  simulate  neuralgia  pretty  closely  whilst  actually  present.  Those 
which  are  next  to  be  mentioned  are  not  distributed  in  neuralgic  areas,  nor  do  they  take 
the  form  of  spontaneous  pain,  but  that  of  unnaturally  heightened  sensitiveness  to  pres- 
sure—the so  called  "  hysteric  hyperassthesia."  This  phenomenon,  as  is  well  known,  is 
quite  superficial,  deep  and  firm  pressure  giving  less  pain  than  that  which  merely  com- 
presses the  skin  or  mucous  membrane  (for  either  may  be  affected).  Here,  again,  faradiza- 
tion has  a  most  legitimate  office;  but  it  needs 4:o  be  applied  with  a  firm  and  unsparing 
hand.  Supposing,  for  instance,  that  the  hypersesthetic  area  is  on  the  skin,  one  uses  dry 
conductors,  one  being  placed  five  or  six  inches  distant,  on  an  indifferent  spot;  the  other 
(which  should  be  in  the  fcJrm  of  the  "  wire-brush  ")  should  be  so  used  as  to  apply  a  kind 
of  electrical  flagellation  to  the  whole  of  the  affected  area.  This  must  be  kept  up  for  sev- 
eral minutes  with  a  powerful  current;  and,  if  the  painfulness  of  the  proceeding  becomes 
intolerable,  it  is  better  to  give  the  patient  a  little  chloroform  and  go  on  (as  Althaus,  1 
believe,  first  suggested)  than  to  do  the  thing  by  halves.  It  is  not  often  that  this  pro- 
cedure fails  to  cure  in  one,  or  at  any  rate  two,  sittings ;  most  frequently  it  is  at  once  suc- 
cessful if  properly  carried  out.  If  the  tender  surface  be  mucous — in  mouth,  rectum,  or 
vagina — the  process  is  still  more  disagreeable.  We  use  metal  conductors  as  before,  but 
of  course  cannot  employ  the  wire-brush  to  the  mucous  surface,  but  a  solid  disc  or  button 
instead,  moving  that  electrode  about  over  the  whole  sensitive  area. 

3.  We  come  now  to  the  large  class  of  cases  in  which  the  pains  are  evidently  situated 
either  in  the  muscular  or  the  tendinous  structures,  and  are  closely  connected  with  the 
degree  in  which  the  muscle  has  been  over-exerted  in  proportion  to  its  nutrition.  These 
"myalgic"  affections  are  also  frequently  in  part  immediately  excited  by  the  action  of 
external  cold  and  damp  upon  a  similarly  under-nourished  muscle.  They  are  distinguished 
by  the  violent  exaggeration  of  the  pain  which  is  caused  by  any  movement  of  the  affected 
part.  There  can  be  no  doubt  that  local  faradization  will  very  usually  remove  these  pains  ; 
the  only  objection  to  its  use  is  that  for  the  most  part  the  aff'ection  is  curable  by  less 
troublesome  and  disagreeable  means.  The  hypodermic  injections  of  morphia,  in  doses 
of  i/^-grain  or  ^-grain,  locally,  or  the  muriate  of  ammonia  (internally)  in  30-grain  doses, 
will  often  give  prompt  relief;  or  Dr.  Reynolds's  plan,  of  sewing  a  piece  of  oilskin  out- 
side the  jersey  over  the  painful  part,  will  do  the  rest.  If  faradization  is  to  be  used,  how- 
ever, it  is  important  to  remember  that  it  can  only  be  successfully  employed  in  one  way, 
namely,  by  strictly  limiting  its  action  to  the  skin.  For  this  purpose  we  must  have  the 
skin  very  dry,  and  use  dry  conductors.  If  we  allow  the  current  to  penetrate  to  the  muscle 
and  set  up  contractions,  we  shall  only  add  to  the  agony  and  render  the  malady  more 
tedious  than  it  is  apt  to  be  naturally. 

This  brings  us  to  the  consideration  of  a  particular  class  of  muscular  pains,  viz.,  those 
caused  by  sudden  laceration  of  fibre,  an  accident  which  is  not  very  uncommon.  Fresh 
interest  in  the  faradic  treatment  of  these  affections  has  been  raised  by  a  recent  case  under 
Professor  Broca,  of  Paris,  although  the  method  is  already  some  years  old.  The  patient 
got  the  injury  in  some  playful  scuffle,  the  arm  being  pushed  forcibly  (in  a  direction  which 
is  not  very  clearly  stated)  while  the  biceps  was  contracted ;  the  latter  muscle  gave  way. 
Local  faradization  was  immediately  employed,  and,  though  painful,  it  immediately  re- 


592  PSYCHOLOGICAL   MEDICINE. 

stored  the  power  of  raising  the  hand  to  the  head.  The  reporter  (M.J.  Lucas-Champion- 
niere)  remarl-cs  on  the  strangeness  of  several  circumstances  connected  with  these  ruptures 
of  muscular  fibres.  He  does  not  seem  inclined  to  think  that  the  contraction  of  the  muscle 
itself  could  produce  the  accident,  but  rather  (with  M.  Broca)  that  the  already  contracted 
muscle  is  torn  by  some  violent  wrench  in  the  direction  of  extension ;  and  is  especially 
liable  to  this  if  its  tissues  be  in  an  unhealthy  state.  But  how  comes  it,  he  asks,  that  a 
method  (faradization)  which  causes  energetic  and  painful  movements  of  the  torn  muscle, 
can  at  once  replace  it  in  a  condition  to  perform  the  usual  voluntary  movements  without 
pain  ?  We  doubt,  however,  if  this  be  quite  an  accurate  statement  of  what  takes  place. 
In  the  first  place,  we  do  not  think  that  faradization,  which  makes  the  7nusde  co7itract,  is 
the  real  agent  at  work.  In  a  case  where  we  personally  used  faradization  with  complete 
success,  the  patient  had  torn  a  portion  of  the  biceps  in  holding  on  to  a  rope  which  had  a 
heavy  weight  at  the  other  end ;  the  machine  employed  was  the  common  rotatory  electro- 
magnetic apparatus,  and  one  of  the  ordinary  brass  handles  was  grasped  by  J:he  sufferer, 
while  the  other  was  moved  about  on  the  skin  over  the  injured  muscle  without  exciting 
any  notable  contraction ;  yet  in  a  few  minutes  the  arm  could  be  flexed  and  extended  pain- 
lessly. The  rupture  was  distinct  and  visible  to  the  eye.  There  is  also,  of  course,  a  proba- 
bility that  muscular  fibres  which  are  completely  divided,  even  if  their  elements  be  made 
to  contract,  would  give  far  less  pain  than  if  their  attachments  had  remained  entire. 

4.  There  is  a  somewhat  indefinite  class  of  so-called  rheumatic  pains  which  appear  to 
be  seated  in  the  ligaments  of  joints,  or  in  the  periosteum  of  bones,  occasionally  also  in 
the  fasciae.  Of  course  (and  more  especially  under  the  periosteal  group)  there  is  a  great 
danger  of  reckoning  cases  that  are  really  syphilitic ;  but,  after  careful  exclusion  of  these, 
a  considerable  number  remain  which  it  is  permissible  to  call  chronic  fibrous  rheumatism. 

.It  is  very  doubtful  whether  faradization  exercises  any  direct  influence  on  this  affection; 
for  our  own  part  we  have  not  been  able  to  obtain  any  decidedly  positive  results,  and  are 
inclined  to  suppose  that  cases  which  have  appeared  to  be  relieved  were  really  of  a  my- 
algic  nature.  One  of  the  fairest  instances  in  which  to  test  the  power  of  faradization 
would  be  that  peculiarly  chronic  and  intractable  affection — rheumatism  of  the  plantar 
fascia ;  but  it  must  be  remembered  that,  in  many  persons,  the  skin  of  the  sole  is  so  dense 
and  resistant,  that  there  will  be  no  chance  of  applying  the  electricity  with  sufficient  pene- 
trating force  unless  the  integument  has  first  been  thoroughly  macerated  with  warm  water. 

5.  The  great  question,  however,  is,  whether  faradization  is  of  use  in  true  neuralgia ; 
and  to  this  we  believe  that  a  decided  answer  in  the  negative  must  be  given.  It  is  easy 
enough,  no  doubt,  to  produce  evidence  of  cures  by  faradization  in  what  has  been  called 
neuralgia  by  some  persons ;  but  it  must  be  remembered  that  the  present  tendency  of 
medical  classification  is  to  separate  true  neuralgia  very  distinctly  from  the  various  other 
pains  which  have  been  confounded  with  it.  No  pain  ought  to  be  called  neuralgia  unless 
it  obviously  follows,  on  the  whole,  the  track  of  a  recognizable  nerve ;  tbe  affections  of 
this  class  have  a  very  definite  clinical  and  family  history  which  enables  us  to  identify  the 
disease  as  clearly  as  we  can  identify  any  malady  that  exists. 

There  is  ample  scope  for  testing  the  power  of  faradization  to  relieve  the  pain  of 
genuine  neuralgia,  since  these  are  common  enough,  and,  in  several  forms,  are  so  typical 
that  they  cannot  be  mistaken.  Personally  we  have  tried  faradization  over  and  over  again 
in  distinct  trigeminal,  brachial,  sciatic,  and  cervico-occipital  neuralgias,  and  the  general 
result  of  our  experience  is  quite  clear.  In  a  considerable  number  of  cases,  probably  the 
majority,  the  process  only  aggravates  the  pain;  and  we  have  known  instances  in  which 
a  neuralgia  which,  to  all  appearances,  had  begun  to  recede,  was  at  once  wakened  up  and 
made  worse  than  ever,  and  more  rebellious  to  the  influence  of  ordinary  palliatives  than 
before.     In  other  cases  we  have  seen  momentary  apparent  benefit,  which  seemed  due  to 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  593 

the  nervous  surprise,  so  to  speak ;  but  such  benefit  does  not  endure  (as  it  often  does  in 
hysterical  pseudo-neuralgia) ;   the  pain  soon  returns   again,   and,  if  anything,  with  in-  _ 
creased  violence.     In  other  cases,  again,  faradization  has  produced  no  effect  whatever, 
good  or  bad. 

On  inquiring  further  into  the  matter,  there  are  at  least  two  reasons  why  faradization 
would  be  likely  to  prove  either  indifferent  or  hurtful  in  the  treatment  of  true  neuralgia. 
If  the  current  does  not  penetrate  beneath  the  skin,  the  only  effect  produced  will  be  a 
superficial  irritation,  which  might  (in  a  reflex  manner)  possibly  act  beneficially  if  it  could 
be  kept  up  for  a  long  time  (as  the  effect  of  a  blister  is),  which,  however,  cannot  be  done. 
On  the  other  hand,  supposing  the  current  to  penetrate  more  deeply,  it  is  likely  to  do  mis- 
chief in  either  or  both  of  the  following  ways :  if  it  encounters  the  nerve,  it  inflicts  upon 
it  the  jarring  sensation  which  the  very  nature  of  the  interrupted  current  necessarily  in- 
volves, and  which  we  cannot  but  suppose  must  be  exceedingly  inimical  to  the  restoration 
of  the  irregular  nerve-action  to  a  state  of  equilibrium.  On  the  other  hand,  it  is  difficult 
or  almost  impossible  to  prevent  the  penetrating  current  from  exciting  the  surrounding 
muscles  to  contraction ;  and  it  is  well  known  that  the  most  certain  aggravation  of  neu- 
ralgia is  produced  by  the  dragging  and  squeezing  of  muscular  movement ;  the  strongest 
examples  being  seen  in  the  effects  of  mastication  in  neuralgia  of  the  third  division  of  the 
fifth,  and  of  certain  complicated  muscular  actions  i^e.  g.  pianoforte  playing)  in  brachial 
neuralgia. 

The  above  remarks  give  a  rough  outline  of  the  reasons  why  faradization  is  generally 
useless  or  objectionable  in  true  neuralgia.  In  that  disease  it  is  at  once  desirable  to  act 
on  the  nerve  itself,  and  yet  to  act  with  the  greatest  gentleness  and  steadiness.  The  true 
neuralgias  as  we  have  tried  to  show  elsewhere,  involve  a  real  change  (it  matters  little  now 
whether  we  call  it  atrophy  or  rhythmical  molecular  alteration)  in  the  posterior  or  sensory 
root  of  the  nerve,  and  this  state  is  best  combated  by  such  means  as  tend  gradually  and 
steadily  to  restore  the  nutrition  of  the  nerve.  And,  on  the  other  hand,  clinical  experience 
teaches  us,  very  positively,  that  there  are  no  such  terrible  excitors  and  aggravators  of 
neuralgic  pains  as  repeated  intermittent  impulses.  The  pulsation  of  a  vessel,  for  example, 
which  presses  upon  a  neuralgic  nerve,  sends  thrill  after  thrill  of  pain  through  it,  till  at 
last  the  torture  becomes  unbearable,  even  to  a  patient  who  perhaps  could  endure  well 
enough  a  constant  though  severe  suffering.  Now,  the  intermittency  of  the  interrupted 
current  is  a  matter  of  degree,  and  consequently  the  amount  of  mischief  that  may  be  done 
by  faradization  varies  very  much  according  to  the  apparatus  used  and  the  exact  mode  of 
using  it.  This  brings  us  naturally  to  the  final  remarks  which  we  have  to  make,  which 
concern  the  question  of  apparatus. 

A  fairly  good  faradizer  for  those  cases  in  which  we  desire  to  inflict  a  good  deal  of  pain 
(or  at  least  considerable  nervous  perturbations),  is  the  ordinary  rotatory  magneto-electric 
machine,  which,  till  very  lately,  has  been  absurdly  supposed,  in  this  country,  to  be  efficient 
for  all  electro-therapeutic  purposes  whatever.  There  is  no  question,  however,  that  it  does 
very  well  for  hysterical  pseudo-neuralgia  and  hysterical  hypersesthesia,  especially  if  the 
patient  be  made  to  hold  one  of  the  brass  handles,  and  a  very  coarse  wire  brush  be  used 
as  the  other  electrode,  and  freely  applied  to  the  affected  part.  But  it  is  usually  (except 
for  the  mere  saving  of  trouble)  better  to  use  a  volta-faradaic  apparatus — i.  e.,  one  in  which 
the  motor  power  is  got  from  a  galvanic  or  voltaic  cell ;  and,  for  the  purpose  in  hand,  a 
very  simple  and  inexpensive  apparatus  will  do,  such  as  Hearder's  "  20-power  "  machine, 
though  of  course  it  is  better,  if  possible,  to  supply  oneself  with  a  thoroughly  complete 
instrument,  like  those  of  Stohrer  or  of  Messrs.  Weiss. 

In  dealing,  however,  with  painful  affections  by  means  of  faradization,  there  are  more 
considerations  than  one  to  be  taken  into  account  in  the  choice  of  the  apparatus  to  be  used. 

38 


594  PSYCHOLOGICAL    MEDICINE. 

Besides  mere  questions  of  convenience  in  application,  there  is  the  question,  what  degree 
of  frequency  and  regularity  do  we  desire  in  the  interruptions  of  the  current  ? 

As  a  general  rule,  it  is  true  that,  "  in  irritation  by  induced  currents,  the  more  rapid  the 
interruptions  the  greater  is  the  pain  produced."  The  interruptions  are  rendered  more 
frequent,  or  lower,  by  manipulations  with  screws,  which  place  the  interrupting  hammer 
nearer  to  or  farther  from  the  platinum  point.  But,  in  dealing  with  actual  clinical  cases, 
it  will  not  be  found  that  the  therapeutic  facts  exactly  correspond  with  this  rule.  The  ob- 
ject being  to  create  intense  nervous  surprise  and  distraction,  it  will  not  unfrequently  be 
found  that,  a  current  of  sufficient  intensity  having  been  provided,  a  series  of  interruptions 
which  is  slow  on  the  whole,  but  has  an  irregular  rhythm,  is  more  effective  than  a  me- 
chanically regular  series  of  rapid  interruptions.  It  is  not  easy  to  lay  down  precise  rules 
here,  but  the  following  is  about  accurate  as  a  representation  of  my  own  experience  :  In 
proportion  as  the  malady  is  beyond  the  patient's  own  control,  it  is  desirable  to  employ  a 
regular  series  of  intermissions,  and  vice  versa.  Given,  that  is  to  say,  a  patient  with  none 
of  the  common  convulsive  phenomena  of  hysteria,  but  with  some  definite  paralysis  or 
anesthesia,  and  whose  skin  presents  a  patch  of  acute  hysteric  tenderness ;  then  I  advise 
the  use  of  a  tolerably  intense  current  with  rapid  and  even  intermissions.  The  patient 
should  be  placed  under  chloroform,  and  the  dried  skin  should  be  well  fustigated  with  the 
wire  brush  of  a  StShrer's  or  a  Weiss's  faradizer,  the  secondary  current  being  employed  of 
high  strength.  But  if  the  affection  be  of  that  exceedingly  common  kind  in  which  the 
morbidness  of  the  will  has  much  to  do  with  the  painful  sensations  themselves,  then  it  is  a 
good  plan  to  proceed  differently.  For  such  patients  no  chloroform  should  be  allowed ; 
the  electrodes  should  be  brass  disks,  and  a  common  magneto-electric  apparatus  may  be 
employed.  The  current  being  arranged  at  a  high  degree  of  intensity,  the  driving-wheel 
is  to  be  urged  at  a  varying  and  irregular  pace;  it  will  be  seldom  that  the  morbid  sensa- 
tions do  not  give  way  after  a  few  sittings  conducted  in  this  manner. 

In  speaking  of  the  limitations  of  faradization  as  a  remedy  for  pain,  we  have  not  for- 
gotten, though  we  have  left  so  far  unmentioned,  the  methods  which  are  called  electric 
pencil  and  electric  moxa,and  which  aim  at  producing  a  more  severe  and  continuous  painful 
impression.  Our  own  experience  is  decidedly  in  favor  of  the  abolition  of  such  methods  of 
treating  pain  ;  they  ought  only  to  be  used,  we  think,  for  cases  in  which  there  is  every  reason 
to  think  that  the  whole  symptoms  are  mere  malingering.  If  it  be  really  desirable  to  push 
the  skin  irritation  beyond  the  limits  already  traced,  it  will  be  much  better  to  lay  aside 
electricity  and  resort  to  the  more  prolonged  and  gradual  excitement  which  can  be  pro- 
duced by  blisters  ;  and  if  these  fail  (especially  when  used  in  conjunction  with  hypodermic 
injections  of  moi-phia),  we  must  resort  to  the  constant  current.  In  all  the  true  neuralgias 
there  cannot  now  be  a  question  that  the  latter  is  essentially  the  right,  and  the  only  right, 
form  of  electricity  to  be  employed. 

As  a  parting  word  of  insistence  upon  the  necessity  for  not  employing  faradization  ex- 
cept within  its  proper  limits,  we  must  especially  dwell  upon  one  variety  of  malpractice 
which  has  not  unfrequently  been  followed  by  very  disastrous  results.  We  have  had  oc- 
casion to  know  that  in  cases  of  rachialgia  (spine-ache)  it  is  not  uncommon  for  practitioners 
to  apply  one  pole  of  a  common  magneto-electric  apparatus  to  the  nape  of  the  neck  and 
the  other  to  the  sacrum  or  to  the  feet  (in  a  water-bath),  turning  on  a  pretty  sharp  current. 
Such  practice  is  not  merely  senseless,  it  may  prove  very  dangerous  ;  for  the  shock  which 
is  thus  given  to  the  system  is  much  more  serious  than  that  produced  by  any  amount  of 
pain  inflicted  upon  a  limited  skin  area.  There  is  no  reason  to  think  that  such  faradism 
has  any  direct  effect  upon  the  spinal  cord,  but  in  a  reflex  manner  it  may  have  a  most 
serious  effect;  and  the  greatest  general  prostration,  or  even  paraplegia,  may  be  produced. 
It  is  really  a  heavy  disgrace  to  the  profession  that  such  utterly  reckless  proceedings  can 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  595 

possibly  occur  as  some  which   we  have  personally  known  to  take  place  in  the  supposed 
electrical  treatment  of  what  the  practitioner  was  pleased  to  call  hysterical  pains. 

A  case  of  trigeminal  neuralgia  treated  with  the  constant  current, 
is  reported  by  Samuel  Craddock,  Esq.,  Shepton  Mallet,  England: 

[The  patient  was  64  years  of  age,  and  was  seized  somewhat  suddenly  with  severe  neu- 
ralgia of  the  left  fifth  nerve.  The  foci  of  pain  were  situated  over  the  malar  bone,  and 
at  the  junction  of  the  nasal  cartilage  and  nasal  bone;  also  on  the  brow,  over  the  supra- 
orbital foramen.] 

The  immediate  exciting  cause  of  this  attack  appeared  to  be  that  the  patient  had  stood 
at  an  open  window  during  some  damp  weather  that  was  prevailing  at  the  time.  This 
gentleman  had  been  the  subject  of  severe  albuminuria  of  long  standing;  it  had,  in  fact, 
existed  for  many  years,  but  there  was  no  evidence  of  breaking  down  of  the  kidney-struc- 
ture. At  the  time  of  the  attack  the  urine  was,  moreover,  very  acid,  and  contained  many 
uric  acid  crystals  ;  specific  gravity,  1025. 

The  treatment  at  first  consisted  in  warm  fomentations  to  the  face,  and  the  internal  ad- 
ministration of  alkalies  with  mild  alterative  aperients ;  after  a  few  days  he  seemed  to  im- 
prove, and  the  medicine  was  changed  for  a  mixture  containing  iron,  arsenic,  and  nux 
vomica.  On  October  the  26th  he  went  to  town,  and  consulted  his  London  physician,  who 
regarded  the  attack  as  due  to  the  gouty  diathesis,  and  put  him  anew  upon  alkaline  treat- 
ment. The  patient  returned  to  the  country  on  November  19th,  very  much  worse ;  in 
fact,  I  never  saw  any  one  suffer  so  severely  from  neuralgia.  The  lachrymation  from  the 
left  eye  was  excessive,  and  there  was  a  copious  flux  from  the  left  nostril ;  the  nostril  was 
so  exquisitely  tender  that  he  could  not  bear  to  use  his  pocket-handkerchief.  He  com- 
plained also  of  severe  shooting  pains  passing  throiigh  the  interior  of  the  eye  These 
symptoms  steadily  increased  in  severity,  and  the  branches  of  the  posterior  dental  nerve 
which  are  distributed  to  the  gums,  became  affected,  as  well  as  the  middle  dental  branches 
of  the  supra-orbital;  this  was  indicated  by  pain  referred  to  the  site  of  the  antrum.  All 
the  cutaneous  branches  of  the  superior  maxillary  were  now  alive  with  pain,  and  another 
focus  was  developed  in  the  upper  lip.  The  sensory  part  of  the  inferior  maxillary,  dis- 
tributed to  the  lower  lip,  followed  suit ;  and  at  last,  so  far  as  one  could  see,  every  branch 
of  the  sensoi-y  portion  of  the  left  trigeminus  was  more  or  less  affected.  The  patient  be- 
came perfectly  unable  to  eat  anything  at  all  solid,  and  lived  for  two  months  entirely  upon 
liquids  ;  even  these  he  was  only  able  to  take  through  a  reed  or  a  glass  tube.  It  is  scarcely 
necessary  to  enumerate  the  long  list  of  remedies  which  were  employed ;  they  included  the 
hypodermic  injection  of  morphia  and  atropia,  but  the  patient  could  not  tolerate  these,  and 
the  hypodermic  method  consequently  did  not  obtain  a  fair  and  complete  trial.  The  first 
remedy  that  gave  any  appreciable  relief  was  the  external  application  of  aconite  liniment, 
which  was  done  morning  and  evening,  and  certainly  mitigated  the  pain  ;  meanwhile, 
however,  the  lachrymation  and  the  defluxion  from  the  nose  continued  in  full  force,  as 
also  the  tenderness  of  the  parts.  Early  in  February,  1873,  I  applied  the  constant  cur- 
rent, employing  a  fifty-celled  Weiss's  battery.  The  current  was  derived  from  eight  cells, 
and  was  applied  for  a  period  of  five  minutes  at  each  sitting.  The  positive  pole  was 
placed  at  the  back  of  the  neck,  and  the  negative  applied  successively  to  the  several  foci 
of  pain,  being  kept  steadily  on  each  for  a  minute  or  more.  This  was  done  daily,  at  the 
same  hour ;  after  the  third  application  the  lachrymation  had  nearly  ceased,  and  the  patient 
was  able  to  blow  his  nose  freely.  From  this  time  the  improvement  was  continuous ;  mas- 
tication was  performed  easily,  and  at  the  end  of  a  fortnight  the  cure  was  complete.  The 
patient  could  not  avoid  perceiving  the  remarkable  influence  of  the  galvanism,  and  spoke 


596  PSYCHOLOGICAL   MEDICINE. 

of  it,  with  the  greatest  deHght,  as  a  "  perfect  cure."  My  own  satisfaction  was  equally- 
great,  as  I  had  previously,  from  inexperience  of  its  use,  been  inclined  to  doubt  the  effi- 
cacy of  the  constant  current.  This  case  certainly  speaks  strongly  in  favor  of  this  method 
of  treating  neuralgia,  and  incidentally  supports  the  pathological  theory  of  neuralgia  ad- 
vocated by  Dr.  Anstie  in  his  work  on  that  disease. 

[The  above  case  interests  me  greatly :  I  regard  it  as  a  typical  example  of  the  mistakes 
that  frequently  result  from  the  time-honored  doctrine  that  neuralgia  is  usually  produced 
by  the  gouty  diathesis.  So  long  as  that  theory  was  acted  upon  in  this  case,  no  really 
effective  steps  were  taken  towards  the  arrest  of  the  disease,  and  a  very  little  more  con- 
tinuance in  the  same  course  would  not  improbably  have  rendered  the  malady  incurable, 
considering  the  patient's  advanced  age.  I  understand  from  Mr.  Craddock,  that  there  was 
really  no  positive  reason  for  supposing  that  this  patient  had  gout  in  him ;  and  certainly 
the  mere  presence  of  an  excess  of  uric  acid  in  the  urine  is  no  justification  for  such  an 
assumption.  The  first  remedy  that  made  any  impression  was  the  linimentum  aconiti,  a 
local  application  which  can  only  have  acted  in  one  way,  viz.,  by  temporarily  paralyzing 
the  peripheral  portions  of  the  nerve,  and  thus  blocking  the  channels  by  which  impres- 
sions from  without  were  pouring  in  upon  the  irritated  nerve-centre.  Aconite  belongs  to 
a  small  class  of  remedies  which  are  often  of  great  service  in  procuring  a  momentary  pause, 
during  which  neuralgic  nerves  have  time  to  recover  their  equilibrium  a  little,  while  more 
radical  curative  measures  can  be  devised. 

As  regards  the  action  of  the  constant  current,  there  can  be  no  reasonable  doubt  that 
this  was  genuinely  effective,  and  I  beg  to  call  attention  to  the  fact  that  the  direction  of 
the  current  was  what  is  called  "  inverse,"  viz.,  from  centre  to  periphery.  This  is  contrary 
to  the  method  strongly  advocated  by  many  writers  on  medical  electricity ;  but  the  result 
corresponds  with  that  of  inverse  galvanization  as  seen  in  several  cases  under  my  own 
treatment.  I  may  especially  advert  to  the  case  of  a  footman  (described  in  liiy  book  on 
neuralgia)  in  whom  an  exceedingly  severe  facial  neuralgia  of  the  first  and  second  divisions 
of  the  fifth  was  found  to  be  perfectly  under  the  control  of  the  constant  current,  and  the 
effects  of  inverse  and  of  direct  galvanization  were  found  to  be  practically  identical.  I  take 
this  opportunity  of  remarking  that  evidence  is  fast  accumulating  which  tends  to  show 
that  the  older  ideas  as  regards  the  influence  of  the  direction  of  the  current  must  have 
been  to  a  large  extent  erroneous.  The  opinion  of  Dr.  Reynolds  and  of  Dr.  Buzzard 
coincides  with  my  own  upon  this  matter,  and  has  been  ai-rived  at,  equally  with  my  own, 
by  sheer  experience,  in  the  face  of  unavoidable  prepossessions  in  favor  of  the  usual  ideas 
as  to  the  respective  effects  of  the  two  currents. — F.  E.  Anstie.] 

The  details  of  electrical  examination  and  treatment  in  a  case  of 
peripheral  paralysis  of  the  facial  and  oculo-motor  nerves  are  given 
by  Dr.  Thomas  Buzzard,  Physician  to  the  National  Hospital  for  the 
Paralyzed  and  Epileptic,  England. 

How  far  the  application  of  electricity  is  available  in  paralysis  of  the  external  muscles 
of  the  eyeball  is  a  point  upon  which  some  doubt  is  still  entertained.  In  the  case  which 
is -here  related  an  unusual  method  of  applying  voltaism  to  these  muscles  was  employed 
with  success.  Incidentally  various  points  of  great  interest  in  reference  to  diagnosis  as 
well  as  treatment  arose  in  the  course  of  the  patient's  illness,  and  the  value  of  electrical 
tests  was  shown  no  less  strikingly  than  the  useful  effects  of  voltaism  in  bringing  back 
paralyzed  muscles  to  the  influence  of  the  will. 

I  was  called,  in  December,  1872,  into  the  countiy  by  Dr.  Playne,  of  Maidenhead,  to 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  597 

see  a  gentleman  sixty-two  years  of  age,  under  the, following  circumstances  :  The  patient 
looked  somewhat  older,  than  his  age,  and  had  been  more  or  less  ailing  for  some  years. 
A  year  previously  he  had  suffered  from  some  obscure  mental  symptoms,  which  had  fol- 
lowed prolonged  sleeplessness.  He  was  usually  dyspeptic,  and  had  experienced  pains 
of  rheumatic  character.  On  December  X3th  he  found  in  the  morning  that  on  cleaning 
his  teeth  the  water  ran  out  of  the  right  side  of  his  mouth,  and  his  face  was  observed  to 
be  drawn  over  to  the  left.  Next  day  he  could  not  close  his  right  eye.  When  I  saw  him 
on  December  17th,  there  was  pronounced  paralysis  of  the  right  portio  dura.  There  was 
complete  inability  to  close  the  right  eye ;  the  angle  of  the  mouth  dropped  on  the  right 
side;  in  smiling  the  face  was  drawn  over  to  the  left;  and  when  asked  to  show  his  teeth, 
the  lips  were  scarcely  separated  on  the  right  side,  whilst  on  the  left  the  teeth  were  ex- 
posed in  the  usual  manner.  The  aperture  of  the  mouth,  under  these  circumstances, 
formed  an  irregular  triangle,  with  its  base  disposed  vertically  on  the  left  side.  The 
right  eye  was  painful,  and  watering  from  exposure.  If  there  was  any  impairment 
of  sensibility  to  touch  over  the  right  side  of  the  face,  it  was  very  slight  indeed.  When 
the  conjunctiva  of  the  right  eye  was  touched  with  the  finger-point,  avoiding  the  margin 
of  the  lid,  although  the  pressure  was  perfectly  well  felt,  there  was  no  i-eflex  closure  of 
the  lid. 

Here,  then,  were  the  ordinary  symptoms  of  a  peripheral  paralysis  of  the  portio  dura, 
and  the  fact  that  the  patient  had  been  out  in  his  garden  on  the  evening  before  his  attack 
rather  later  than  usual,  and  that  the  weather  was  cold  and  damp,  combined  towards  the 
probability  of  his  suffering  from  a  rheumatic  affection  of  the  nerve,  or  at  least  from  a 
condition  referable  to  the  influence  of  cold. 

I  had  the  opportunity  of  applying  electrical  tests.  I  found  that  neither  faradaism  nor 
the  interrupted  voltaic  current  would  excite  the  right  facial  ne^-ve.  As  regards  the  facial 
muscles  of  the  right  side  there  was  no  reaction  to  the  strongest  faradaic  current  which 
could  be  borne,  but  when  I  applied  to  them  the  rheophores  connected  with  a  Stohrer's 
constant  batteiy,  using  four  cells  only,  and  slowly  intermitting  the  current,  I  obtained 
marked  contraction  of  those  situated  about  the  angle  of  the  mouth.  A  similar  power 
applied  in  like  manner  to  the  muscles  of  the  sound  side  of  the  face  produced  no  reaction. 
The  sensibility  of  the  skin  of  the  face  was  decidedly  lowered  on  the  right  side,  espe- 
cially below  the  eye,  both  to  touch  and  to  the  pain  of  faradaism.  The  latter  fact  was 
peculiarly  well  marked.  The  grasp  of  both  hands  was  weak,  but  not  definitely  unequal, 
and  the  patient  could  raise  either  leg  against  pressure  equally  well.  There  was  no  marked 
impairment  of  sensibility  in  his  hands,  but  on  inquiry  he  said  that  there  was  slight  numb- 
ness of  the  finger-points  on  both  ^ides.  There  was  no  diminution  in  the  power  of  tast- 
ing on  the  right  side  of  the  tongue.  There  was  not  then,  and  there  never  had  been,  any 
weakness  in  the  external  rectus  muscle  of  the  right  eye.  I  examined  the  urine,  which 
was  pale,  clear,  acid,  and  of  specific  gravity  1013.  It  contained  no  trace  of  sugar  nor 
of  albumen.  There  was  general  derangement  of  the  digestive  functions,  with  a  furred 
tongue  and  some  diarrhoea.  The  patient  was  ordered  a  quarter  of  a  grain  of  nitrate  of 
silver,  with  one-fifth  of  a  grain  of  opium,  twice  a  day,  and  an  effervescing  mixture  of 
citrate  of  potash  and  soda,  with  grain  doses  of  iodide  of  potassium. 

As  regards  the  diagnosis,  I  thought  there  were  sufficient  grounds  for  believing  that  the 
lesion  lay  in  some  part  of  the  course  of  the  portio  dura.  Had  it  been  at  the  deep  origin 
of  the  nerve,  it  was  unlikely  that  the  sixth  nerve,  which  (according  to  Lockhart  Clarke) 
arises  from  the  same  nucleus  as  the  facial,  in  the  floor  of  the  fourth  ventricle,  would  have 
remained  unaffected.  Moreover,  and  this  was  the  most  important  feature,  the  electric 
reaction  was  distinctly  that  indicating  peripheral  paralysis.  When  the  facial  nerve  is 
paralyzed  from  central  disease,  it  is,  according  to  my  experience,  always  the  case  that  the 


598  PSYCHOLOGICAL    MEDICINE. 

facial  muscles  retain,  either  entirely  or  in  great  part,  their  power  of  being  excited  by 
faradaism.  On  the  other  hand,  the  absence  of  excitability  by  faradaism  and  the  exag- 
gerated influence  of  interrupted  voltaism  were  completely  characteristic  of  facial  paral- 
ysis a  frigore.  I  advised,  and  it  was  agreed,  that  treatment  by  interrupted  voltaism  should 
be  employed. 

On  the  7th  March,  then,  nearly  three  months  after  the  seizure,  this  treatment  was  com- 
menced, and  afterwards  continued  almost  daily  for  three  weeks.  Stohrer's  constant  cur- 
rent battery  was  employed,  at  first  four  cells  being  engaged,  then  six,  and  finally  eight. 
One  rheophore  was  placed  on  the  cheek  at  the  point  where  the  facial  nerve  breaks  into 
its  two  great  divisions,  and  the  other  at  various  parts  of  the  face;  but  especially  often 
near  the  ala  of  the  nostril.  The  current  thus  employed  caused  vigorous  contractions  of 
many  muscles  affecting  the  nostril  and  mouth.  At  other  times  one  rheophore  was  ap- 
plied near  the  outer  canthus,  and  then  the  current  caused  contractions  of  the  orbicularis 
palpebrarum  muscle.  Each  sitting  occupied  about  twenty  minutes.  One  rheophore  was 
lifted  and  reapplied  at  tolerably  regular  intervals  of  about  thirty  or  forty  in  the  minute. 
During  the  first  week  the  change  effected  by  this  treatment,  although  at  once  apparent, 
was  not  very  marked;  but  afterwards  improvement  was  noticed  daily.  On  March  28th, 
when  the  patient  returned  into  the  country,  the  cheek  no  longer  bagged ;  the  lower  lip 
kept  closed,  instead  of  falling  and  showing,  as  it  had  done,  the  lining  membrane,  over 
which  saliva  trickled ;  the  eye  could  be  very  nearly  closed.  Nor  was  this  improvement 
altogether  the  result  of  a  secondary  contraction  equivalent  to  that  so  often  seen  in  the 
paralyzed  muscles  in  a  case  of  hemiplegia,  for  a  very  considerable  power  of  moving  the 
mouth  by  voluntary  effort  returned.  The  nerve-twigs  to  the  occipito-frontalis  muscle 
must,  I  think,  have  escaped  injury.  At  all  events,  when  I  tested  the  frontal  part  of  this 
muscle  a  few  days  after  beginning  the  treatment  described,  I  found  that  it  responded 
readily  to  the  faradaic  current  when  one  rheophore  was  placed  over  the  emergence  of 
the  portio  dura  and  the  other  on  the  muscle.  It  was  also  capable  of  being  contracted 
by  voluntary  effort.  Nearly  two  years  had  elapsed  when  I  was  again,  on  May  28th, 
1S75,  summoned  to  see  this  patient.  I  found  him  in  his  bedroom,  sitting  up,  with  his 
back  to  the  light,  which  his  left  eye  was  quite  unable  to  tolerate.  So  much  photophobia 
was  there  that  I  had  to  refrain  from  turning  his  face  to  the  window  whilst  I  examined 
him.  The  left  eye  was  closed  by  ptosis  of  the  upper  lid,  but  the  patient  could,  by  a 
strong  voluntary  effort,  open  it,  though  the  lid  immediately  afterwards  fell.  There  was 
intense  pain,  referred  to  the  ball  of  the  eye,  and  also  pain,  together  with  tenderness  on 
pressure,  upon  the  left  parietal  bone,  near  its  junction  with  the  frontal.  He  had  double 
vision,  the  images  being  crossed — that  to  his  right  belonging  to  his  left  eye.  In  order 
to  avoid  the  confusion  and  giddiness  caused  by  this  diplopia,  he  was  wearing  a  shade 
over  the  left  eye.  I  found  that  there  was  partial  paralysis  of  the  branches  of  the 
left  oculo-motor  nerve,  going  to  the  levator  palpebrss  superioris,  the  internal,  superior, 
and  inferior  rectus  muscles.  It  seemed  that  the  patient  had  been  exposed  to  a  great 
deal  of  domestic  trouble  and  anxiety,  with  the  result  that  his  appetite  and  digestion  had 
failed,  and  a  few  days  before  I  saw  him,  he  had  complained  of  double  vision.  It  ap- 
peared also  that  several  decayed  teeth,  which  had  been  troubling  him  for  some  time,  had 
interfered  with  his  power  of  taking  sufficient  nourishment.  I  advised  some  chloride  of 
ammonium,  which  seemed  to  have  a  good  result  as  far  as  the  pain  in  the  eyeball  was 
concerned.  A  fortnight  later,  however,  I  found  that,  whilst  he  had  ceased  to  feel  pain 
in  the  globe  of  the  eye,  the  paralysis  of  the  muscles  before  referred  to  as  partial  had  be- 
come complete.  There  was  complete  ptosis,  and  absolute  inability  to  turn  the  left  eye 
either  upwards,  downwards,  or  towards  the  nose.  The  symptoms  indicating  an  affection 
of  the  left  third  nerve,  which  might  be  accompanied  or  caused  by  some  effusion  in  its 


ELECTRICITY    IN    DISEASES    OF    THE    NERVOUS    SYSTEM.  599 

sheath,  I  advised  a  trial  of  iodide  of  potassium,  although  very  doubtful  whether  it  would 
be  tolerated.  In  effect,  the  first  dose  so  upset  the  patient's  stomach  that  he  could  not  be 
induced  to  try  another,  and  Dr.  Playne  then  prescribed  some  quinine,  ammonia,  and 
gentian.  This  answered  very  well ;  the  appetite  and  general  health  improved,  and  when 
the  patient  came  to  town  on  July  7th,  I  found  him  looking  much  better  than  he  had  been. 
There  was  still,  however,  ptosis  of  the  left  eyelid.  He  could,  when  requested,  lift  the 
lid  to  a  certain  extent  by  a  manifest  effort,  but  it  was  immediately  dropped.  The  vision 
of  this  eye  not  being  absolutely  occluded  by  the  state  of  the  lid,  he  was  forced  to  cover 
it  with  a  shade,  as  otherwise  he  was  so  embarrassed  by  diplopia  that  he  could  not  walk 
without  staggering.  I  found  the  recti  muscles  greatly  wanting  in  power,  but  not,  I  think, 
quite  so  incapable  as  when  I  had  last  seen  him.  However,  the  eye  was  turned  outwards 
constantly,  and  although,  by  a  strong  voluntary  effort,  it  could  be  carried  a  very  little  way 
towards  the  nose,  and  a  still  less  distance  upwards  and  downwards,  it  was  practically 
fixed  in  a  condition  of  external  strabismus,  and  was  useless  for  optical  purposes. 

Guided  by  my  experience  of  the  result  of  interrupted  voltaism  in  the  facial  paralysis 
of  the  opposite  side  of  the  face  more  than  two  years  previously,  I  thought  it  likely,  now 
that  acute  symptoms  had  subsided,  that  a  similar  mode  of  treatment  might  lead  to  good 
results  in  restoring  the  action  of  the  muscles  of  the  eyeball  which  were  paralyzed.  In- 
structed, too,  by  former  experience,  I  felt  that  faradaism  was  not  the  treatment  proper 
for  the  condition.  The  muscles  of  the  right  side  of  the  face  had  quite  failed  to  respond 
to  faradaism,  but  they  were  excited  by  a  very  mild  voltaic  current  when  it  was  slowly 
interrupted.  So  it  seemed  likely  that  a  mild  and  interrupted  voltaic  current  was  indi- 
cated in  the  present  condition.  The  best  mode  of  applying  this  was  not  so  evident. 
When  metal  rheophores  covered  with  wetted  kid  were  applied  to  the  closed  lids,  and  a 
current  of  varying  strength  employed,  either  the  electric  influence  was  unfelt  or  it  was 
painful  to  the  skin.  There  was  difficulty,  too,  both  with  these  rheophores  and  also  with 
sponges  in  applying  the  stimulus  exactly  where  I  wished  it.  I  now  bethought  me  of 
using  the  finger  as  a  rheophore,  and  tried  it  in  the  following  manner:  An  assistant  having 
applied  to  the  patient's  left  temple  a  sponge  rheophore  connected  with  one  (it  was  not 
material  which)  pole  of  a  Stohrer's  constant  current  battery,  I  grasped  in  my  left  hand 
another  sponge  rheophore  coming  from  the  other  pole,  and  then  applied  the  forefinger  of 
my  right  hand,  covered  with  a  single  thickness  of  muslin  wetted  with  pure  water,  to  the 
right  upper  eyelid  of  the  patient.  The  battery  was  Weiss's  (Foveaux's),  which  had  con- 
siderably run  down,  so  that  it  was  perhaps  only  half-strength.  Cautiously  increasing  the 
number  of  cells  (it  was  long  before  any  electric  sensation  was  felt),  I  found  that  the 
current  from  between  30  and  40  cells  could  be  employed  in  this  manner,  my  body, 
through  which  it  was  bound  to  pass,  offering  a  great  resistance,  and  serving  indeed  as  a 
rheostat.  The  application  was  made  through  the  closed  lids.  The  finger  proved  an 
exceedingly  convenient  rheophore.  I  could  apply  exactly  the  amount  of  pressure  desira- 
ble, and  could  reach  portions' of  the  globe  which  it  would  have  been  exceedingly  difficult 
to  act  upon  in  any  other  manner.  Moreover,  the  strength  of  the  current  could  be  gauged 
at  every  instant.  That  which  was  employed  was  just  sufficient  to  cause  me  to  feel  a 
distinct  shock  in  the  knuckle  of  my  "right  forefinger  every  time  the  current  was  interrupted. 
Occasional  flashes  of  light  were  observed  by  the  patient,  but  he  felt  no  pain.  We  thought 
we  could  see  a  little  improvement  in  power  after  the  first  day's  application,  but  there  was 
no  doubt  of  this  at  all  at  the  close  of  the  second  sitting.  Not  to  weary  with  a  daily 
record,  I  may  say  that  this  treatment  was  applied  on  fifteen  occasions  in  all,  the  applica- 
tions extending  over  a  period  of  three  weeks.  The  time  occupied  at  each  sitting  was 
from  twenty  to  thirty  minutes.  A  daily  increase  in  power  of  the  muscles  was  noted,  and 
when  the  patient  returned  home,  after  the  last  application,  he  was  absolutely  well.     The 


600  PSYCHOLOGICAL   MEDICINE. 

lid  was  entirely  under  control,  and  the  movements  of  the  left  eye  were  in  every  respect 
perfect.  Of  course,  therefore,  there  was  no  longer  any  double  vision,  and  the  use  of  the 
shade  was  discarded.     The  patient  has  since  remained  quite  well. 

Remarks. — I  need  scarcely  say  that  it  is  a  matter  of  the  gravest  import,  as  regards  the 
prognosis,  whether  a  paralysis  of  the  facial  muscles  is  diagnosed  as  peripheral  or  as  de- 
pending on  a  lesion  of  the  central  nervous  system.  The  importance  of  this  is  increased 
when  the  patient,  as  in  this  case,  is  a  man  who  has  passed  the  middle  period  of  life;  and 
becomes  intensified  when,  as  occurred  in  the  instance  which  I  have  described,  paralysis 
of  one  side  of  the  face  is  followed  by  loss  of  power  in  certain  muscles  of  the  eye  on  the 
opposite  side.  The  general  conditions,  the  patient's  age,  his  weak  state  of  health,  his 
family  history,  all  combined  to  give  a  very  serious  aspect  to  his  case,  which  even  his 
complete  recovery  would  not  of  itself  suffice  to  counterbalance.  For  it  is  quite  conceiv- 
able that  a  man  of  this  age,  and  with  such  a  history,  might  suffer  from  a  central  nervous 
lesion,  possibly  small  hemorrhages,  which  could  be  repaired,  and  the  paralytic  symptoms 
be  ipso  facto  removed,  and  yet  that  he  might  be  left  in  a  state  peculiarly  prone  to  the 
repetition  of  attacks  which  might  at  any  moment  involve  districts  where  the  occurrence 
of  lesion  would  have  a  serious  influence  upon  life.  The  mere  fact,  therefore,  of  this 
patient's  complete  recovery  does  not  of  itself  bear  conclusive  testimony  to  the  peripheral 
character  of  the  affections  from  which  he  suffered.  The  electric  reaction,  however,  of 
the  facial  muscles  paralyzed  in  the  first  attack  lends  complementary  evidence  of  a  kind 
sufficient,  I  believe,  to  enable  us  to  say  that  not  only  was  that  attack  certainly  dependent 
upon  a  lesion  of  some  part  of  the  facial  nerve,  not  of  the  nervous  centre,  but  that  in  all 
probability  the  second  attack  was  of  similar  character.  Experience,  which  by  this  time 
has  been  sufficiently  universal  to  make  its  results  positive,  teaches  us  that  when  there  is 
paralysis  of  facial  muscles,  and  these  a  few  hours  after  the  attack  show  a  diminution, 
rapidly  going  on  to  an  entire  abolition  of  contractility  on  exposure  to  induced  currents, 
whilst  contractility  is  effected  with  abnormal  facility  by  the  interrupted  voltaic  current, 
the  lesion  is  not  a  central  one,  but  involves  some  portion  of  the  portio-dura  nerve.  I 
have  seen  no  exception  to  this  rule.  The  lesion  may  result  from  cold,  from  wound  of 
the  nerve,  or  from  compression,  but  it  is  always  a  lesion  of  the  nerve,  and  not  of  the 
nervous  centre.  It  was  with  great  confidence,  therefore,  that  when  the  test  applications 
of  the  induced  and  voltaic  currents  in  this  case  were  followed  by  the  results  described,  I 
pronounced  the  facial  paralysis  to  be  of  peripheral  origin.  When,  in  process  of  tihie,  the 
second  attack  occurred,  involving  on  this  occasion  the  oculo-motor  nerve  of  the  opposite 
side,  although  in  the  nature  of  things  the  application  of  electrical  testing  was  not  practi- 
cable, it  was  not  unreasonable  to  infer  that  this  also  depended  upon  a  similar  cause  to 
that  which  had  caused  facial  paralysis  two  years  previously,  especially  as  isolated  paralysis 
of  one  oculo-motor  nerve  is  almost  always  peripheral.  I  ought  especially  to  say  that 
there  was  good  reason  to  exclude  the  probability  of  syphilis  in  this  case,  and  that  there 
has  not  been  any  sign  of  gout.  My  prognosis  was  accordingly  favorable,  as  regards  the 
question  of  the  site  of  the  lesion,  although  I  could  not  properly  give  any  decided  opinion 
upon  the  question  whether  the  paralysis  would  be  recovered  from  or  remain  permanent. 
I  inclined,  however,  to  the  more  favorable  view,  and  thought  that  electrical  treatment 
would  be  likely  to  assist  recovery. 

The  voltaic  instead  of  the  faradaic  current  was  chosen,  then,  because  the  paralysis  of 
the  eye  muscles,  like  that  of  the  facial  muscles,  was  deemed  to  be  of  peripheral  character. 
It  seems  likely,  especially  from  the  researches  of  Schiff,  that  induced  currents  do  not 
determine  directly  the  contraction  of  muscles,  but  only  act  through  the  medium  of  the 
intra-muscular  nerves.  When  these  are  damaged,  as  by  the  influence  of  cold,  the  power 
of  causing  contraction  of  the  muscles  by  faradaism  ceases.     Not  so,  however,  as  regards 


ELECTRICITY    IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  6oi 

the  interrupted  voltaic  current,  tlie  influence  of  which  is  now  much  more  marlted  than  it 
is  in  healthy  striated  muscle.  Dr.  Onimus,  of  Paris,  in  some  interesting  papers  which 
have  lately  appeared,  expresses  the  opinion  that  iii  cases  of  paralysis  of  the  facial  nerve  the 
muscles,  although  they  do  not  atrophy,  pass  into  a  condition  in  which  the  contractile  sub- 
stance resembles  rather  smooth  muscular  fibre  or  protoplasm  than  normal  striated  muscle. 
He  reminds  us  that  continuous  currents  have  a  much  more  marked  action  upon  smooth 
fibres  than  induced  currents,  and  to  provoke  the  contraction  of  the  unstriated  fibres  a 
current  of  much  less  intensity  is  required  than  for  striated  muscles.  And  as  with  normal 
smooth  fibres,  so  also  with  those  striated  fibres  which,  from  an  injury  to  the  intra-muscular 
nerves,  have  acquired  much  of  the  character  of  smooth  muscular  fibre.  In  this  mode, 
Dr.  Onimus  explains  the  remarkable  difference  between  the  action  of  the  induced  current 
and  that  of  voltaism  in  cases  of  facial  paralysis,  as  well  as  the  curious  fact  that  the  voltaic 
current  acts  much  more  energetically  in  such  cases  than  in  the  healthy  condition.  In  the 
case  above  related,  it  seems  probable  that  the  branches  of  the  portio  dura  distributed  to  the 
muscles,  and  not  to  the  trunk  of  the  nerve  itself,  were  affected.'  For  the  occipito-frontalis 
muscle  escaped,  and  this  omission,  which  is  easily  explained  if  the  lesion  be  supposed  to 
be  located  in  a  number  of  nervous  twigs,  some  of  which  elude  the  hurtful  influence, 
presents  considerable  difficulty  if  we  imagine  an  injury  to  the  trunk  itself.  Moreover, 
the  sense  of  taste  was  preserved  on  the  affected  side,  which  suggested  that  the  lesion  was 
at  least  beyond  the  point  where  the  chorda  tympani  is  given  off.  The  impairment  of  the 
cutaneous  sensibility,  which  was  certainly  more  marked  than  I  am  in  the  habit  of  finding 
it  in  such  cases  (there  is  often  a  little  numbness),  is  probably  to  be  explained  by  a  localized 
influence  upon  the  branches  of  the  sensory  nerve  (fifth)  similar  to  that  exerted  upon  those 
of  the  portio  dura.  The  exact  effect  upon  the  muscles,  which  was  brought  about  rapidly 
by  the  influence  of  voltaism,  I  do  not  find  it  easy  to  explain.  It  would  seem — and  this 
point  is  extremely  interesting — that  if  we  cut  off  the  influence  of  the  will  from  striated 
muscular  fibre,  the  structure  tends  to  degrade,  and,  as  regards  its  function,  passes  into  a 
state  closely  resembling  that  which  is  characteristic  of  involuntary  muscular  fibre.  The 
resemblance  is  threefold:  the  fibre  is  no  longer  contracted  by  the  influence  of  the  will; 
it  is  acted  upon  by  voltaism  when  faradaism  fails  to  affect  it;  and  the  action  of  voltaism 
upon  it  is  much  more  marked  than  upon  healthy  striated  muscle.  Apparently  the  effect 
of  applying  voltaic  currents  to  muscular  fibre  so  degraded  is  to  lead  it  back  to  its  normal 
condition.  It  often  happens,  as  it  did  in  this  case,  that  the  will  acquires  its  power  to 
cause  contraction  of  the  recovering  muscles  before  they  will  respond  to  the  influence  of 
the  induced  current,  but  after  they  have  ceased  to  be  abnormally  excited  by  voltaism. 
When  this  occurs,  it  is  probably  only  a  question  of  time  as  to  when  faradaism  will  be 
able  to  exert  its  ordinary  stimulating  power  once  more.  When  I  last  tested  this  gentle- 
man's facial  muscles,  a  few  weeks  ago,  I  found  that  voluntary  power  over  them  was 
restored  perhaps  to  three-quarters  of  the  normal  extent,  that  interrupted  voltaism  affected 
the  injured  in  no  higher  degree  than  the  uninjured  side,  and  that  the  influence  of  the 
induced  current  had  again  become  manifest,  though  not  quite  perfectly.  I  suppose  that 
voltaism  replaced  the  action  of  the  will,  as  far  as  concerned  the  preservation  of  the 
muscular  fibres,  till  such  time  as  the  intra-muscular  nerves  had  recovered  and  allowed 
the  passage  of  the  volitional  influence.  The  circumstance  that  the  face  has  not  entirely 
recovered  is,  doubtless,  owing  to  the  injury  to  some  of  the  muscular  nerves  having  been 
irreparable.  There  is  nothing,  it  seems  to  me,  in  such  examples  as  this,  which  requires 
one  to  fall  back  upon  an  electrolytic  action  of  voltaism  upon  the  constituents  of  the  nerve- 
trunk  to  account  for  phenomena  which  are  to  be  explained  more  easily  in  the  manner 
described.  I  think  that  the  very  rapid  clearing  up  of  the  oculo-motor  palsy  (in  the  second 
attack)  under  the  influence  of  voltaism  goes  far  to  prove  that  the  lesion  in  this,  as  in  the 


602  .  PSYCHOLOGICAL    MEDICINE. 

other  paralytic  seizure,  was  of  a  superficial  character.  The  injury  at  the  time  electrical 
treatment  was  commenced  was  probably  to  a  great  extent  repaired,  but  the  muscles  which 
had  been  cut  off  for  a  long  time  from  the  stimulating  influence  of  the  will  had  degraded 
into  a  state  approaching  that  of  involuntary  muscular  fibre,  and  were  incapable,  therefore, 
of  being  acted  upon  by  volition  to  any  effective  purpose.  The  few  applications  of  voltaism 
restored  the  muscular  fibres  to  their  natural  condition,  and  they  became  both  physically 
and  metaphysically  "voluntary." 

The  use  of  the  hand  as  a  rheophore  is  not  new.  It  has  been  employed  by  many  for 
the  application  of  faradaism,  especially  to  the  spinal  column.  But,  as  far  as  I  am  aware, 
the  use  of  the  finger  in  the  manner  described  for  applying  interrupted  voltaism  to  the  eye 
muscles  is  novel.  It  is  certainly  very  convenient.  What  we  want  in  such  a  case  is  a 
large  quantity  of  electricity  of  low  tension,  and  this  is,  I  think,  especially  well  arrived  at 
by  interposing  the  operator's  body  in  the  course  of  the  current,  and  employing  a  consid- 
erable number  of  cells. 

Respecting  the  treatment  of  certain  forms  of  paralysis  by  galvan- 
ization and  faradization,  Dr.  Julius  Althaus,  Physician  to  the  Royal 
Infirmary  for  Diseases  of  the  Chest,  London,  says : 

[There  are  only  two  forms  of  current  required  for  therapeutic  purposes,  viz.,  the  induced 
or  interrupted  electro-magnetic  and  the  continuous  galvanic  current,  the  methodical  em- 
ployment of  which  has  been  tenned  respectively  "  faradization  and  galvanization." 
Frictional  electricity  possesses  no  peculiar  advantages,  while  the  magneto-electric  current 
is  decidedly  inferior  to  the  electro-magnetic] 

The  double-current  induction  machine  and  the  modification  of  Daniell's  battery,  both 
constructed  according  to  my  directions  by  Mr.  Becker,  of  the  firm  of  Messrs.  Elliott  Bro- 
thers, of  St.  Martin's  Lane  and  the  Strand,  are  sufficient  for  all  practical  purposes.  The 
former  of  these  apparatuses  is  similar  to  the  induction  machines  which  are  now  in  gen- 
eral use  on  the  Continent,  whilst  the  constant  battery  just  mentioned  is,  for  beauty  and 
efficiency  of  arrangement,  superior  to  any  that  have  hitherto  been  contrived.  In  those 
constant  batteries  which  have  until  now  been  used  by  medical  men,  the  great  drawback 
has  been  the  presence  either  of  nitric,  sulphuric,  or  chromic  acid,  which  not  only  after  a 
time  destroy  the  battery,  but  also  entail  considerable  variations  in  the  power  of  the  cur- 
rent and  much  loss  of  time  on  the  part  of  the  operator.  It  -was,  therefore,  desirable,  in 
the  construction  of  a  battery  suited  for  medical  practice,  to  dispense  with  acids  altogether 
in  order  to  render  the  current  as  constant  as  possible  and  to  avoid  inconvenience  and  loss 
of  time.  For  these  reasons  the  machine  mentioned  is  only  charged  with  water  and  a 
solution  of  sulphate  of  copper,  with  the  result  that,  after  having  been  once  put  into  action, 
a  constant  current  is  obtained  which  continues  reliable  for  about  six  months,  even  if  the 
battery  is  daily  used.  No  acid  being  present,  the  cast  zinc  cannot  be  destroyed,  and 
remains  quite  unchanged.  After  the  lapse  of  the  period  mentioned  the  deposit  of  cop- 
per must  be  removed  from  the  zinc  plates  and  a  fresh  solution  of  sulphate  of  copper  be 
substituted.  If  this  be  occasionally  repeated  the  battery  will  last  for  any  length  of  time, 
while  most  constant  batteries,  when  daily  used,  are  destroyed  in  about  a  twelvemonth, 
and  some  even  in  so  short  a  space  as  six  weeks.  Another  advantage  of  the  absence 
of  acid  in  this  battery  is  that  the  current  gains  in  quantity  while  it  loses  in  tension, 
and  can,  on  this  account,  be  safely  used  for  acting  on  the  centres  of  the  nervous 
system. 

The  physical  relations  and  the  chemical  and  physiological  effects  of  the  continuous 
and  the  interrupted  current  are  widely  different  from  one  another,  and  it  may,  therefore, 


ELECTRICITY   IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  603 

be  inferred  that  each  one  of  them  has  also  its  own  special  sphere  of  action  in  therapeutics. 
The  continuous  current,  which  is  produced  by  the  chemical  action  of  two  heterogeneous 
conducting  bodies,  moves  always  in  the  same  direction  and  has  considerable  chemical 
effects,  as  it  easily  decomposes  water  and  saline  solutions,  oxygen  and  acids  being  attracted 
to  the  positive  pole,  while  hydrogen  and  alkalies  accumulate  at  the  negative  pole.  In- 
duction currents,  on  the  contrary,  are  of  instantaneous  duration,  move  alternately  in  con- 
trary directions,  and  have,  therefore,  only  a  slight  chemical  action,  for,  as  each  wire 
serves  alternately  as  positive  and  negative  pole,  their  chemical  effects  are,  in  a  great 
measure,  neutralized  as  soon  as  produced.  As  regards  the  difference  in  the  physiological 
action  of  the  two  currents,  it  may  be  laid  down  as  a  fundamental  principle  that  the 
induced  current  only  acts  07i  the  parts  directly  subinitted  to  its  influence  unless  a  very  high 
power  be  used,  while  the  conti7iuous  current,  by  reflex  action,  also  affects  distant  parts, 
and  more  especially  the  centres  of  the  nervous  syste?n.  As  this  is  a  new  proposition,  it 
will  be  necessary  to  adduce  proofs  in  order  to  establish  its  correctness. 

If  the  induced  current  is,  by  moistened  conductors,  applied  to  the  face,  it  causes  a 
peculiar  sensation  and  contraction  of  the  muscles,  while  the  continuous  current,  if  applied 
in  the  same  manner,  not  only  causes  a  peculiar  sensation  and  a  contraction  of  the  muscles 
both  at  its  commencement  and  at  its  cessation,  but  also  a  vivid  flash  of  light,  and  if  the 
current  be  one  of  some  force,  even  sickness,  giddiness,  and  fainting  may  ensue.  These 
latter  phenomena,  which  are  caused  at  whatever  part  of  the  face  or  nape  of  the  neck  the 
current  may  have  been  applied,  can  only  be  explained  by  assuming  the  physiological 
transmission  of  part  of  the  current  to  the  encephalon.  There  are  also  facts  to  prove  that 
the  continuous  current  has  a  physiological  action  on  the  spinal  cord  and  the  sympathetic 
nerve  if  applied  to  the  skin  of  the  back  by  moistened  conductors.  Thus  we  may  often 
cause  the  iris  to  contract  by  directing  a  current  of  large  quantity  to  the  lower  cervical 
and  upper  dorsal  veitebrse,  showing  that  there  is  physiological  transmission  of  part  of  the 
current  to  the  cillo-spinal  region  of  the  cord  and  the  corresponding  ganglia  of  the  sym- 
pathetic which  preside  over  the  functions  of  the  iris.  Again,  by  applying  a  continuous 
current  to  the  lumbar  portion  of  the  spine  we  may  cause  a  glow  in  the  legs  and  feet  with- 
out any  direct  application  to  these  latter,  showing  that  the  influence  on  animal  tempera- 
ture, which  M.  Claude  Bernard  and  Dr.  Brown-Sequard  have  proved  to  belong  to  the 
sympathetic,  is  brought  into  play  by  the  application  of  the  continuous  current.  These 
facts  would  appear  sufficient  to  establish  the  correctness  of  the  proposition  with  which  I 
started,  viz.,  that  the  continuous  current  is  capable  of  influencing,  by  reflex  action,  the 
centres  of  the  nervous  system, — both  cerebro-spinal  and  sympathetic,  while  the  induced 
or  interrupted  current  has  no  distant,  but  only  local  and  immediate  effects. 

The  therapeutical  experience  I  have  gained  in  various  forms  of  paralysis  with  both 
kinds  of  current,  entirely  coincides  with  these  physiological  premises.  It  is  to  the  effect 
that  the  interrupted  current  proves  useful  in  local  paralysis,  due  to  injury  of  the  mo- 
tor nerves  and  muscles,  to  pressure,  rheumatic  effusions,  poisoning  by  lead,  etc.,  but 
can  have  a  beneficial  influence  in  paralysis  from  diseases  of  the  nervous  centres  only 
after  the  original  lesion  has  subsided,  and  in  reflex  paralysis  only  after  the  irritation  in 
the  spinal  cord  has  passed  off.  The  continuous  current,  on  the  other  hand,  proves 
efficient  in  certain  forms  of  paralysis  due  to  affections  of  the  nervous  centres,  more 
especially  in  those  cases  which  are  caused  by  effusion  in  the  spinal  canal  and  incipient 
softening  of  the  cord,  as  well  as  in  most  instances  of  reflex  paralysis  where  irritation  of 
the  cord  is  still  present. 

[The  author  illustrates  the  therapeutical  use  of  galvanization  and  faradization  in  par- 
alytic diseases  by  a  short  series  of  cases  which  have  been  under  his  care  in  private 
aird  hospital  practice.] 


604  PSYCHOLOGICAL    MEDICINE. 

I.  Faradization. 

1.  Cerebral  Paralysis. — Faradization  is  useful  in  cases  of  hemiplegia  after  the  complete 
formation  of  the  apoplectic  cyst,  when  there  is  no  longer  any  irritation  within  the  cra- 
nium ;  where  the  speech  is  little  or  not  affected  ;  where  there  is  not  much  or  no  muscu- 
lar rigidity,  but  where  the  arm  and  leg  remain  nearly  or  entirely  useless. 

Case. — -A  gentleman,  aged  45,  had  an  attack  of  hemiplegia  of  the  right  side,  in  June, 
1863.  I  was  consulted  in  April,  1864,  when  there  was  complete  loss  of  power  in  the 
arm  and  only  slight  recovery  of  power  in  the  leg,  the  patient  being  just  able  to  walk  a 
short  distance  with  the  aid  of  another  person's  arm.  Articulation  satisfactory ;  no  rigidity ; 
nutrition  in  paralyzed  limbs  much  below  par.  Faradization  for  six  weeks,  after  which 
the  patient  could  write,  dress,  and  feed  himself,  and  walk  a  couple  of  miles,  with  the  aid 
of  a  stick,  without  much  inconvenience. 

2.  Paralysis  of  the  Portio  Dura. — Where  this  is  due  to  rheumatic  effusions  in  the 
sheath  of  the  facial  portion  of  the  nerve  or  in  the  muscles  themselves,  faradization  is 
a  very  certain  remedy,  more  especially  where  the  contractility  of  the  muscles  is  lost 
or  diminished.  On  the  contrary,  where  the  intracranial  portion  of  the  nerve  is  suf- 
fering, a  continuous  current  of  low  tension  (from  five  to  fifteen  cells  of  the  battery 
previously  described)  proves  more  useful.  This  latter  often  causes  contractions  of  the 
muscles  where  a  powerfully  induced  current  fails  to  do  so. 

Case.- — A  lady,  aged  42,  was  affected  with  left  facial  paralysis  in  Januar}',  1862. 
She  consulted  me  four  months  after  the  commencement  of  the  affection,  when  the  only 
muscles  which  had  recovered  their  tone,  to  a  certain  extent,  were  the  frontal  and  cor- 
rugator,  but  all  others  were  still  completely  paralyzed.  Uvula  straight;  no  deafness. 
Faradization  for  a  fortnight.  Improvement  after  the  first  operation.  Cure  at  the  end 
of  the  second  week. 

I  have  treated  a  number  of  cases  of  intracranial  paralysis  of  the  portio  dura  by  the 
aid  of  the  continuous  current,  but  as  in  ever}'  one  of  them  other  active  remedies  were 
administered  at  the  same  time,  I  will  not  give  any  particulars,  but  merely  say  that 
there  was  no  doubt  about  the  beneficial  effect  of  galvanization  in  these  cases,  not  only 
with  regard  to  the  gradual  recovery  of  power,  but  also  to  the  relief  of  pain,  which 
is  scarcely  ever  absent. 

3.  Rheumatic  Paralysis. — Cases  of  loss  of  power  in  the  extremities,  arising  from 
exposure  to  damp  and  cold,  even  if  of  a  severe  kind  and  of  long  standing,  are  gen- 
erally cured  by  faradization,  which  also  relieves  the  muscular  pains,  which  are  some- 
times very  severe. 

Case. — A  gentleman,  aged  37,  having  been  much  given  to  fishing  and  hunting,  suffered 
for  three  years  from  great  pain  and  loss  of  povv^er  in  the  upper  as  well  as  the  lower  ex- 
tremities, which  he  himself  attributes  to  continual  exposure  to  the  weather.  I  saw  him 
in  October,  1S58,  when  there  was  much  wasting  of  muscular  tissue,  especially  in  the 
right  deltoid  and  the  extensors  on  the  back  of  the  forearm.  No  signs  of  central  disease. 
The  urine  has  been  very  thick,  but  is  now  normal.  After  five  weeks'  faradization  the 
patient  recovered. 

4.  Paralysis  from  Pressure  on  N^ervous  Plexuses. — Cases  of  loss  of  power  from  con- 
tinued pressure,  especially  of  the  head  on  the  arm  during  intoxication  either  by  chloro- 
form or  alcohol,  are  generally  curable  by  faradization. 

Case. — A  lady,  aged  twenty-three,  had  her  first  confinement  in  November,  1864,  dur- 
ing which  she  was  for  some  time  under  the  influence  of  chloroform.  While  in  this  con- 
dition her  head  rested  heavily  on  the  left  arm,  and  pressed  so  much  on  the  brachial  plexus 
that  a  number  of  muscles  animated  by  the  latter  became  entirely  paralyzed,  there  being 
also  complete  anaesthesia  of  the  left  arm.     I  saw  her  in  January,  1865.     The  affection 


ELECTRICITY   IN    DISEASES    OF   THE    NERVOUS    SYSTEM.  605 

was  most  severe  in  the  muscles  of  the  forearm,  the  patient  being  quite  unable  to  lift  the 
wrist,  which  was  much  swollen,  and  had  to  be  bound  up  with  a  splint.  As  she  also 
complained  of  great  weakness  in  the  other  limbs  and  the  back,  I  combined  the  use  of  a 
continuous  current  of  fifty  cells  to  the  spine,  with  faradization  of  the  left  shoulder  and 
arm.  After  six  weeks  of  this  treatment,  the  patient  felt  very  much  stronger  generally, 
and  had  entirely  recovered  the  use  of  the  left  arm. 

5.  Pa7alysis  from  Interrupted  Continuity  betzveen  the  Spinal  Cord  and  Motor  Nerves 
{Dr.  Marshall  Hair s  Spiftal  Paralysis). — Where  the  connection  of  motor  nerves  with 
the  spinal  cord  has,  by  external  violence,  been  interrupted,  a  period  varying  from  six 
to  twelve  months  is  required  for  re-establishiug  nervous  conduction.  The  two  cases  re- 
cently published  by  MM.  Nelaton  and  Laugier,  which  would  seem  to  throw  doubts  upon 
this  point,  are,  in  my  opinion,  not  sufficient  to  make  us  give  up  the  above  proposition, 
which  has  been  deduced  from  most  careful  clinical  observation  of  a  very  large  number 
of.  cases,  as  well  as  from  physiological  experiments  on  animals.  Experience  shows  that 
faradization  soon  or  immediately  after  such  accidents  is  useless,  and  does  not  even  pre- 
vent atrophy  of  the  muscles  deprived  of  their  connection  with  the  cord.  On  the  con- 
trary, if  resorted  to  from  six  to  twelve  months  after  the  accident,  faradization  frequently 
restores  the  power  to  the  paralyzed  muscles. 

Case. — A  porter,  aged  thirty-two,  suffered  compound  fracture  of  the  right  arm  and 
other  injuries  from  being  run  over  by  a  van  in  December,  i860.  After  three  months  the 
fracture  was  healed  but  the  arm  remained  useless.  He  was  sent  to  me  in  May,  1861, 
when  I  found  complete  anaesthesia,  paralysis,  atrophy,  and  loss  of  electric  contractility 
of  the  muscles  from  the  acromion  downwards.  I  recommended  him  to  do  nothing  for 
three  months,  and  then  to  present  himself  again.  This  he  did  in  the  October  following, 
when  he  appeared  to  be  much  in  the  same  condition.  I  then  commenced  the  faradaic 
treatment,  and  after  about  four  months,  the  patient  attending  every  other  day,  he  had,  to 
a  great  extent,  recovered  the  use  of  the  arm,  although  it  was  still  much  weaker  than  pre- 
vious to  the  accident. 

6.  Reflex  of  Paralysis. — In  cases  of  this  kind,  faradization  proves  beneficial  after  the 
irritation  which,  by  its  transmission  to  the  spinal  cord,  caused  the  paralysis,  has  subsided, 
but  where  paralysis  nevertheless  continues.  In  other  cases  faradization  or  galvanization 
may  remove  the  irritation,  and  thus  prove  curative.  For  cases  see  my  work  on  Paraly- 
sis, Neuralgia,  etc.,  pp.  155-158. 

7.  Hysterical  Paralysis. — Where  this  affection  occurs  in  only  one  limb,  or  a  par- 
ticular set  of  muscles,  faradization  of  the  suffering  parts  is  of  use,  but  where  it  appears  in 
the  form  of  hemiplegia,  paraplegia,  or  general  paralysis,  galvanization  of  the  nervous 
centres  is  more  effectual.  (See  a  case  of  this  description  in  the  Lancet  for  February  18th, 
1865,  p.  175.) 

8.  Lead-Palsy. — In  paralysis  from  poisoning  by  lead,  good  results  are  generally 
obtained  by  faradization,  even  in  severe  cases,  and  after  muscular  atrophy  has  set  in. 

Case. — A  painter,  aged  thirty-three,  had  for  more  than  a  twelvemonth  suffered  from 
weakness  of  sight,  colics,  and  dropping  of  both  wrists.  He  had  had  a  long  course  of 
iodide  of  potassium,  under  which  he  somewhat  improved,  but  not  one  of  the  symptoms 
was  entirely  removed.  I  saw  him  in  November,  1864,  and  treated  him  by  galvanization 
of  the  optic  nerve  and  abdomen,  and  faradization  of  the  suffering  muscles.  Within  a 
month  he  was  so  much  improved  that  he  could  be  discharged. 

9.  Progressive  Muscular  Atrophy. — There  are  two  forms  of  this  disease — viz.  :  the 
partial,  which  begins  in  the  hand  or  the  shoulder,  and  does  not  affect  any  muscles  but 
those  of  the  upper  extremities;  and  the  general  form,  which  may  destroy  nearly  all  the 
voluntary  muscles  throughout  the  body,  and  is  mostly  fatal.     Cases  of  the  former  affec- 


6o6  PSYCHOLOGICAL   MEDICINE. 

tion  are  curable  by  faradization ;  and  such  of  the  latter  kind  may  be  considerably  im- 
proved, and  their  course  be  arrested  by  a  combined  use  of  faradization  of  the  muscles 
and  galvanization  of  the  nervous  centres,  if  resorted  to  at  an  early  stage  of  the  dis- 
order. 

Case. — A  gardener,  aged  twenty-five,  became,  in  consequence  of  overwork,  very  weak 
and  lost  flesh  in  the  right  arm  and  shoulder,  in  August,  1863.  During  the  following  two 
months  the  affection  spread  to  the  forearm  and  hand,  and  he  was  then  quite  unable  to 
follow  his  employment.  He  was  sent  to  me  in  December,  1863,  when  I  found  atrophy 
of  most  of  the  muscles  of  the  right  upper  extremity.  Faradization  for  nearly  five  months, 
after  which  the  power  of  the  muscles  had  so  much  increased  that  the  patient  could  return 
to  his  occupation. 

10.  Paralysis  of  the  Vocal  Cords. — As  Dr.  Morell  Mackenzie  has  lately  published  a 
number  of  cases  of  aphonia  due  to  a  paralytic  condition  of  the  vocal  cords,  and  success- 
fully treated  by  faradization,  I  will  only  say  that  my  experience  in  this  particular  quite 
agrees  with  that  of  Dr.  Mackenzie. 

II.  Galvanization. 

1.  Cerebral  Paralysis. — In  certain  cases  of  cerebral  paralysis  with  intracranial  irrita- 
tion, a  cautious  use  of  the  continuous  galvanic  current  proves  of  decided  benefit,  in  al- 
laying pain,  spasms,  and  muscular  rigidity.  I  abstain  from  giving  cases  of  this  descrip- 
tion, as  in  every  one  of  them  which  have  fallen  under  my  notice,  other  remedies  were 
administered  at  the  same  time.  The  continuous  cnrrent  is  likewise  useful  in  cases  with- 
out pain  and  spasm,  but  when  the  speech  is  much  affected  and  the  paralysis  of  arm  and 
leg  continues  ;  and  it  can  be  safely  employed  about  six  months  after  a  seizure. 

2.  Ptosis,  Double  Vision,  and  other  Paralytic  Affectio7is  of  the  Third,  Fotirth  and 
Sixth  Nerves,  a}id  of  the  Iris. — In  these  conditions,  even  if  they  are  caused  by  encephalic 
disease,  the  continuous  current,  cautiously  and  gently  applied,  may  produce  very  strik- 
ing results.  For  the  majority  of  such  cases,  five  or  ten  cells  of  the  battery  are  quite 
sufficient,  and  the  operations  must  be  very  short ;  for  long  and  strong  applications  only 
do  harm.  An  able  and  elaborate  paper  on  the  subject  by  Dr.  Benedikt  of  Vienna, 
may  be  found  in  Von  Graefe's  Archive  filr  Ophthalmologie,  1864,  vol.  x.,  part  i.,  p.  97. 

Cases. — A  gentleman,  aged  forty-nine,  had  for  ten  months  suffered  from  ptosis  of  the 
left  eyelid,  for  which  he  had  undergone  a  variety  of  treatment  without  benefit,  when  he 
consulted  me  in  December,  1864.  There  were  many  other  symptoms  exciting  the  sus- 
picion of  encephalic  disease.  Galvanization  by  five  cells,  for  not  more  than  half  a  min- 
ute each  time.  Within  the  fortnight  he  had  recovered  the  power  over  the  eyelid,  al- 
though there  was  no  improvement  in  the  other  symptoms. 

A  lady,  aged  forty-five,  suffered  from  mydriasis  of  the  right  eye.  She  was  otherwise 
in  good  health,  and  unable  to  account  for  this  affection.  She  was  sent  to  me  in  July, 
1862.  Galvanization  by  three  cells  of  Bunsen's  battery,  with  immediate  improvement 
during  the  first  operation.     She  left  town  after  four  operations,  much  improved. 

3.  Incipient  and  Progressive  Softening  of  the  Spinal  Cord. — In  this  affection  good  re- 
sults may  be  obtained  by  the  application  of  a  powerful  continuous  current,  of  from  fifty 
to  a  hundred  cells  of  Daniell's  battery,  to  the  spine.  Such  operations,  when  judiciously 
performed,  evidently  exercise  a  direct  influence  on  the  nutrition  of  nervous  matter.  In 
the  late  stages  of  the  disorder — that  is  where  actual  destruction  of  nervous  matter  has 
taken  place— of  course  no  benefit  can  be  obtained. 

Dr.  Drescher,  of  Reinerz,  reports  in  the  Allgemeine  Medicinische 
Central-Zeitung,  for  January  22d,  1868,  a  case  of  the  recovery  of  a 


ELECTRICITY    IN    DISEASES    OF   THE   NERVOUS    SYSTEM. 


607 


man  struck  by  lightning,  in  which  very  singular  markings  were  pro- 
duced on  the  body  by  the  lightning. 

The  man  was  sitting  with  his  back  against  a  wall.  When  struck,  he  sank  unconscious 
to  the  ground,  and  seven  minutes  afterwards,  when  first  seen  by  Dr.  Drescher,  he  had 
ceased  breathing  entirely,  and  his  pulse  was  almost  imperceptible.  The  skin  was  cold, 
the  countenance  pale,  the  eyes  half  closed,  and  the  mouth  open.  Frictions  were  made 
on  the  face,  neck,  breast,  and  back ;  and  a  vein  was  opened,  from  which  blood  flowed, 
although  at  first  very  slowly.  The  first  obvious  respiration  was  now  made,  and  gradu- 
ally the  skin  became  warmer,  and  color  returned  to  the  face.  Half  an  hour  after  the 
accident,  the  patient  began  to  moan,  and  at  the  end  of  an  hour  he  had  fully  recovered 
consciousness,  but  was  unable  to  swallow  or  to  speak  above  his  breath  for  half  an  hour 
more. 

He  now  began  to  suffer  the  most  violent  pains,  accompanied  by  intermittent  convulsive 
movements  in  the  flexors  of  the  extremities.  These  gradually,  in  the  course  of  an  hour, 
fixed  themselves  in  the  forearms,  and  wrung  from  the  patient  loud  screams.  He  described 
the  feeling  to  be  as  if  his  arms  were  being  torn  off  at  the  elbow.  These  pains  were  worse 
first  in  one  arm  and  then  in  the  other,  but  finally  fixed  themselves  in  the  left  arm,  became 
endurable,  and  at  last  ceased  almost  entirely  after  about  thirty-six  hours,  leaving,  how- 
ever, the  general  sensibility  of  the  skin  diminished. 

During  eight  years  before,  the  patient  had  at  intervals  suffered  from  an  obstinate  in- 
termittent fever,  from  which,  however,  he  had  been  for  a  long  time  entirely  free ;  but 
eight  hours  after  having  been  struck  by  lightning,  he  had  a  regular  attack,  which  was 
repeated  two  days  afterward,  at  which  time  the  pains  in  the  forearm  returned  with  con- 
siderable violence. 

Quinia,  morphia,  and  wine  were  the  principal  medicines  given. 

The  marks  on  the  body  began  at  the  first  cervical  vertebra,  from  which  they  spread  in 
four  directions.     Two  branches  passed  around  the  neck,  one  on  one  side  and  the  other 


/    \ 

A     i', 


l\ 


on  the  other,  gave  off  branches  on  each  shoulder,  and  then  spread  themselves  all  over 
the  thorax ;  two  other  branches  went  over  the  scapulae  towards  the  axillae. 

All  the  lesser  branches  had  a  downward  and  outward  direction.  The  color  was  a  cop- 
pery brown,  which  from  time  to  time  changed  to  one  a  little  lighter. 

From  the  sacrum  another  line,  an  inch  wide,  ascended.  It  had  the  same  color  as  the 
descending  one,  and  branched  off  similarly;  the  branches  of  the  two  meeting  on  the 
back  just  below  the  scapulae,  and  on  the  abdomen  above  the  umbilicus. 

On  the  extremities  there  were  only  rudimentary  indications  of  markings,  which  were 
a  little  more  evident  on  the  left  arm  than  elsewhere. 

The  separate  points  shown  in  the  engravings  were  as  clear  as  if  the  patient  had  been 
tattooed. 

All  the  markings  disappeared  within  thirty-six  hours. 


6o8  PSYCHOLOGICAL   MEDICINE. 


CHAPTER  XXXI. 

SPINAL  CONCUSSION ITS  MEDICO-LEGAL  RELATIONS  AND  SIGNIFICANCE. 

In  this  chapter  I  propose  to  treat  of  a  class  of  injuries  to  the 
cerebro-spinal  nervous  system,  where  the  effects  are,  as  a  rule,  re- 
mote rather  than  immediate,  and  which,  in  many  instances,  affect  the 
mmd  quite  as  seriously  as  the  body. 

The  immediate  constitutional  state  after  an  injury  to  the  spine 
may  be  one  of  prostration  and  shock  to  the  nervous  system,  in  which 
we  find  our  patient  perhaps  partly  unconscious,  with  a  feeble  pulse 
and  imperfect  respiration.  There  may  be  complete  syncope,  with 
the  pulse  and  respiration  not  perceptible,  or  the  nervous  instead  of 
the  vascular  system  may  be  principally  affected,  and  the  patient  may 
be  incoherent  or  perhaps  comatose.  Nausea,  vomiting,  suppression 
of  urine,  and  convulsions,  especially  in  children,  may  occur.  The 
local  effects  in  injuries  of  the  back  are  not  included  in  the  scope  of 
this  chapter,  and  comprise  wounds,  contusions  of  every  kind,  frac- 
tures, and  dislocations.  Injuries  to  the  backs  of  children  may  occur 
from  blows  or  falls,  without  any  obvious  lesion  of  a  mechanical  na- 
ture occurring,  and,  after  some  time  elapsing,  we  shall  see  our  little 
patient  complaining  of  a  good  deal  of  pain,  and  upon  examination 
we  shall  discover  redness  and  swelling  in  the  tissues,  and  with  the 
history  of  a  fall  or  blow  on  the  back  we  can  at  once  diagnosticate 
the  existence  of  caries.  Finally,  in  these  cases,  an  abscess  forms, 
and  after  our  incision,  to  let  out  the  pus,  we  shall  easily  feel  the  cari- 
ous bone  with  our  probe.  The  abscess  leaves  fistulous  openings, 
from  which  there  is  more  or  less  sanious  pus  discharged,  and  the 
fistulous  opening  is  surrounded  by  unhealthy  granulations. 

These  cases  occur  from  injuries  to  the  back  much  more  frequently, 
I  think,  than  is  imagined  by  the  profession.  In  a  violent  injury  to 
the  back  of  an  adult,  the  shock  is  the  first  thing  that  occurs,  and  our 
patient  may  die  immediately,  with  no  apparent  mechanical  lesion. 
If  our  patient  survives  the  shock,  inflammation  sets  in  and  our  pa- 
tient may  develop  a  meningitis.  The  symptoms  of  severe  concussion 
are  pallor  of  the  face,  the  respiration  gasping  and  afterwards  becom- 
ing nearly  normal,  pupils  dilated,  difficulty  in  swallowing,  pulse  feeble 
and  perhaps  slow,  and  the  consciousness  muddled.  The  patient  might 
appear  to  be  feigning.      We  may  possibly  have  unconsciousness. 


SPINAL    CONCUSSION — ITS    MEDICO-LEGAL    RELATIONS,    ETC.      609 

In  these  most  severe  cases  the  cord  is  contused,  and  if  our  patient 
dies  and  we  make  an  autopsy,  we  may  find  a  little  red  point  of  ex- 
travasation. 

In  these  cases  we  should  use  for  stimulants  carbonate  of  ammo- 
nia or  alcohol  moderately,  with  bags  of  hot  sand  to  the  body,  with 
friction.  Hypodermics  of  y^^  grain  of  sulphate  of  atropia  are  also 
indicated  as  the  most  energetic  heart  and  respiratory  stimulant. 
When  our  patient  recovers  from  the  immediate  shock,  he  will  have 
confusion  of  ideas.  He  may  have  nausea  and  vomiting,  which  are 
good  signs,  as,  when  the  injury  is  very  severe,  our  patient  will  not 
vomit,  and  he  may  not  if  the  injury  is  very  slight.  If  the  brain  is 
implicated,  as  it  may  be,  and  there  is  no  compression,  we  shall  find 
dilated  pupils,  a  comatose  condition,  the  respiration  stertorous,  and 
the  cheeks  and  the  alae  of  the  nose  moving  at  each  movement  of 
respiration.  The  velum  palati  is  paralyzed,  and  there  is  rattling  of 
mucus  in  the  throat.  The  pulse  is  slow  and  laborio.us.  If,  at  the 
end  of  ten  days  after  a  severe  injury  to  the  back,  the  patient  has 
slight  rigors  and  becomes  partially  or  wholly  unconscious,  we  are  to 
infer  that  inflammation  has  been  set  up  and  that  suppuration  has 
taken  place.  These  cases  are  almost  always  fatal.  We  may  have  a 
paraplegia,  or  we  may  have  epileptiform  convulsions.  The  paralysis, 
if  it  occurs,  is  caused  by  haemorrhage  of  some  of  the  vessels  of  the 
cord,  coming  on  as  reaction  comes  on,  or,  in  a  few  days  or  weeks,  as 
the  result  of  contraction  of  lymph  or  pus.  There  may  possibly  be 
a  fracture  without  apparent  mechanical  lesion,  and  in  these  cases  we 
shall  get  either  antero-posterior  or  lateral  deformity  of  the  injured 
part  of  the  spine.  If  the  injury  occurs  above  the  fourth  cervical 
vertebra,  the  pressure  on  the  phrenic  nerves  will  give  rise  to  death 
from  apncea.  In  these  cases  the  respiration  is  stopped  either  at  once 
or  in  a  few  days. 

If  an  injury  occur  to  the  back  in  the  dorsal  region,  we  find  paral- 
ysis of  the  upper  extremities  and  paralysis  of  the  bowels.  We  may 
diagnose  a  possible  fracture,  even  if  not  apparent.  If,  in  an  injury 
to  the  back  in  the  lumbar  region,  we  get  paralysis  of  all  the  parts 
below  the  seat  of  injury,  we  may  also  diagnose  a  possible  fracture, 
although  not  necessarily. 

We  should  never,  in  suspected  fractures  of  the  spine,  endeavor  to 
get  crepitus.  A  fracture  here  will  probably  kill  our  patient,  while 
patients  not  very  unfrequently  recover  from  fracture  in  the  dorsal 
region.     In  a  suspected   fracture  we  should  put  the  patient  on  his 

39 


6lO  PSYCHOLOGICAL   MEDICINE. 

back  and  make  extension  and  counter-extension,  and  union  may  take 
place.  We  should  put  our  patient  with  any  serious  injury  to  the 
back  on  a  water-bed,  so  as  to  get  equable  pressure,  and  use  a  catheter 
three  or  four  times  in  the  course  of  twenty-four  hours.  If  there  is 
tendency  to  paralysis,  a  pill  of  croton  oil,  strychnia,  and  colocynth 
may  be  used. 

Injuries  to  the  back  may  be  complicated  with  fractures  of  the  hip, 
where  there  may  be  fracture  of  the  cervix  within  the  capsule, — an 
extra-capsular  fracture, — or  fracture  of  the  brim  of  the  acetabulum 
or  of  the  floor  of  the  acetabulum.  We  may  possibly  get,  as  a  com- 
plication, dislocation  of  the  hip.  There  is  no  class  of  surgical  inju- 
ries of  more  interest  to  the  neurologist  and  to  the  general  prac- 
titioner who  is  interested  in  diseases  of  the  nervous  system  than 
those  which  come  under  the  head  of  injuries  to  the  spine  and  spinal 
concussion. 

No  injury  to  the  spine,  however  slight,  arising  from  shocks  to  the 
body  generally,  as  in  railway  accidents,  or  from  the  ordinary  accidents 
we  meet  with  in  general  practice,  comprising  falls,  blows,  being 
thrown  from  a  carriage,  is  too  trivial  to  be  overlooked,  as  the  spinal 
cord  may  be  functionally  disturbed,  and  even  organically  diseased 
from  any  and  all  such  shocks  and  injuries.  We  may  have  local  and 
constitutional,  immediate  and  remote  effects  from  these  injuries.  The 
primary  effects  of  a  concussion  of  the  spinal  cord  are  due  to  molecular 
changes  in  the  structure  of  the  cord,  while  the  secondary  effects  are 
of  an  inflammatory  character,  consisting  of  meningo-myelitis,  disturb- 
ances of  nutrition,  with  great  mental  and  moral  depression. 

There  is  often  change  of  character,  irritability  of  temper,  and  often 
impairment  of  some  of  the  special  senses.  Death  may  occur  after 
chronic  inflammation  of  the  membranes  and  cord,  lasting  for  three 
or  four  years,  during  which  time  our  patient's  health  has  gradually 
been  breaking  down,  with  slow  extension  of  paralytic  symptoms. 
The  symptoms  may  be  immediate  or  they  may  develop  slowly  after 
an  interval  of  some  months.  In  a  direct  injury  to  the  spine  we  may 
find  our  patient  with  a  bruise  on  his  back,  with  pain  on  pressure, 
with  consciousness  intact,  with  partial  paraplegia,  and  with  more  or 
less  numbness.  Febrile  reaction  sets  in  and  lasts  for  a  few  days, 
during  which  time  he  may  not  be  able  to  empty  his  bladder,  neces- 
sitating the  use  of  the  catheter  every  six  hours.  We  may  find 
a  great  latitude  as  to  the  extent,  degree  and  relative  amount  of 
paralysis  of  motion   and    of  sensation  in  any  given  case.      If  the 


SPINAL    CONCUSSION — ITS    MEDICO-LEGAL    RELATIONS,    ETC.       6ll 

direct  blow  is  on  the  dorsal  or  lumbar  vertebrae,  paraplegia  usually 
results. 

Sensation  is  necessarily  affected,  spasm  and  rigidity  of  the  mus- 
cles may  occur,  the  sphincters  may  be  involved  and  we  shall  have 
much  pain.  There  may  be  incontinence  of  urine  or  there  may  be 
partial  or  complete  retention.  Low  temperature  is  the  rule  in  spinal 
injuries,  a  high  temperature  when  we  meet  with  it  being  indicative 
of  inflammatory  troubles.  When  we  find  a  fatal  result,  it  is  due  to 
haemorrhage,  laceration,  extravasation,  or  to  inflammatory  softening, 
and  our  patient's  recovery  may  be  complete  or  incomplete.  A  con- 
siderable length  of  time  may  elapse  between  a  spinal  concussion  or 
injury  to  the  back  and  the  development  of  the  symptoms  of  the  in- 
jury, which  may  be  so  slight,  perhaps,  as  to  attract  little  attention  at 
the  time;  just  as  we  have  seen,  in  a  previous  part  of  this  work,  that 
brain  tissue  degenerations  and  mental  diseases  may  be  separated  by 
long  intervals  of  time  from  the  too  premature  and  intense  stimulation 
of  the  brain,  which  causes  these  nerve  and  brain  diseases.  This  is  a 
very  important  medico-legal  point.  The  muscular,  tendinous  and 
ligamentous  structures  of  the  spinal  column  may  be  very  violently 
wrenched  and  sprained  by  injury  or  concussion,  without  injury  to  the 
cord  itself  These  cases  may  recover  in  a  few  weeks,  or,  in  delicate 
persons,  they  may  lay  the  foundation  for  serious  organic  disease.  If 
inflammation  is  developed  in  the  fibrous  structures,  it  may  extend  to 
the  meninges  of  the  cord,  and  this  possible  danger  should  not  be 
overlooked  or  ignored  in  our  prognosis.  Our  patient  may  slowly 
develop  cerebral  symptoms  from  the  extension  upwards  of  menin- 
geal irritation.  After  a  spinal  concussion  it  is  not  at  all  uncommon  for 
our  patient  to  undergo  a  gradual  change,  both  mentally  and  physi- 
cally, and  he  is  never  the  same  man  again.  He  gradually  becomes 
an  invalid,  unable  to  apply  his  mind  to  business,  or  to  stand  the  or- 
dinary cares  and  worries  of  life,  which  previous  to  his  injury  had 
never  troubled  him.  There  is  decided  mental  failure,  which  may 
proceed  to  complete  imbecility  or  insanity.  The  mental  responsi- 
bility of  such  a  person  is  greatly  lessened,  and  his  testamentary  ca- 
pacity may  be  also  affected.  When  injury  of  the  back  is  severe 
enough  to  produce,  at  the  time  of  the  injury,  unconsciousness,  insen- 
bility,  stupor  or  syncope,  then  the  severity  of  the  concussion  is  such 
as  to  produce  an  immediate  injury  of  the  gravest  nature  to  the  cen- 
tral nervous  system,  and  never'-  afterwards  does  such  an  individual 
have  complete  restoration  to  health.      After  a  concussion  of  the 


6l2  PSYCHOLOGICAL    MEDICINE. 

spine,  many  weeks  or  months  may  elapse  before  the  more  positive 
and  distressing  symptoms  occur.  In  the  interval,  however,  our  pa- 
tient suffers  from  poor  health,  his  nervous  power  has  gone  and  his 
face  is  anxious  and  careworn. 

His  memor}^  is  defective,  his  thoughts  are  confused,  his  business 
aptitude  is  lost,  his  temper  is  changed,  his  sleep  is  poor,  and  his 
special  senses  impaired.  There  is  also  loss  of  motor  power  and  a 
diminution  of  sensation  in  the  limbs.  The  patient  at  first  complains 
of  weariness  on  slight  exertion,  either  mental  or  physical,  followed 
by  the  modifications  in  sensibility,  pain  and  rigidity  of  spine,  cere- 
bral disturbance,  and,  as  I  have  remarked,  loss  of  motor  power. 
When  there  is  myelitis,  the  sensibility  is  at  first  augmented,  and 
then,  as  the  myelitis  becomes  chronic,  the  gait  is  very  much  affected. 
Whether  acute  or  chronic,  myelitis  is  much  more  apt  to  attack  the 
lower  portions  of  the  cord  than  the  upper,  and  when  it  attacks  the 
upper  portion  of  the  cord,  and  we  get  cerebral  complications,  we 
may  be  sure  we  have  more  or  less  spinal  meningitis.  The  coexis- 
tence of  meningitis  and  myelitis  is  what  we  generally  find  in  our 
patients  who  have  suffered  from  severe  injuries  to  the  spine.  I 
think  it  is  rare  to  find  inflammations  of  the  spinal  membranes  limited 
to  the  spinal  canal,  and  that  there  is  an  extension  of  the  morbid 
process,  which  gives  us,  as  a  result,  an  increased  vascularity  and  in- 
flammation of  the  arachnoid.  In  spinal  meningitis  we  have,  as  the 
most  marked  symptom,  severe  pain  along  the  spine  and  down  both 
legs.  These  attacks  of  pain  may  be  separated  by  intervals  of  almost 
complete  ease  and  comfort.  The  pain  is  soon  accompanied  by  stiff- 
ness of  the  muscles  of  the  back  and  legs.  Any  movement  of  the 
body,  neck  or  legs,  gives  rise  to  pain.  There  is  absence  of  paraly- 
sis, some  exaltation  of  sensibility,  loss  of  power  over  the  bladder 
and  partial  loss  of  power  over  the  bowels.  There  is  absence  of  spinal 
tenderness,  and  there  is  also  an  absence  of  marked  spasmodic 
symptoms.  In  proportion  as  the  higher  portions  of  the  cord  are 
affected,  there  is  difficulty  of  mastication  and  deglutition.  Difficulty 
of  breathing  generally  is  present.  There  is  a  little  sympathetic  fever, 
and  there  may  or  may  not  be  cerebral  symptoms.  There  is  no  in- 
creased reflex  excitability. 

Myelitis  is  characterized  by  paraplegic  ansesthesia  ushered  in  by 
tingling  in  the  parts,  which  soon  become  anaesthetic.  The  para- 
plegia is  preceded  by  restlessness  rather  than  by  more  marked 
symptoms.      There  is   a  very  uncomfortable    feeling    of  tightness 


SPINAL    CONCUSSION — ITS    MEDICO-LEGAL    RELATIONS,    ETC.       613 

around  the  waist  or  elsewhere,  as  a  constant  symptom  in  myelitis. 
There  is,  as  a  rule,  absence  of  pain,  except  when  our  patient  is  suf- 
fering from  the  combined  meningo-myelitis,  of  which  I  shall  pres- 
ently speak.  In  simple  myelitis,  I  do  not  think  we  have  much  pain 
in  the  spine  or  extremities.  There  is  an  absence  of  spasmodic 
symptoms.  As  a  very  early  symptom  there  is  a  want  of  control 
over  the  bladder,  which  depends  upon  a  paralysis  of  the  accelerator 
urinal  and  compressor  urethral  muscles.  There  is  a  want  of  control 
over  the  rectum  also,  caused  by  paralysis  of  the  sphincter  ani.  There 
is  absence  of  tenderness  on  pressure  in  any  part  of  the  spine. 
There  is  an  altered  sensibility  to  heat  and  cold,  by  which  a  feeling  of 
burning  is  felt  when  a  sponge  soaked  in  moderately  warm  water,  or 
a  piece  of  ice  is  applied  immediately  above  the  seat  of  inflammation. 
There  is  annihilation  of  reflex  excitability.  There,  is  diminution  of 
electro-motility  and  electro-sensibility  in  the  paralyzed  muscles. 
There  may  or  may  not  be  priapism.  The  urine  is  generally  alkaline, 
but  neither  always  or  necessarily  so.  There  is  marked  difficulty  in 
breathing.  The  state  of  the  circulation  is  asthenic.  There  is  a 
tendency  to  bed-sores,  and  there  is  in  simple  myelitis  absence  of 
head  symptoms.  In  a  patient  who  has  suffered  a  severe  injury 
to  his  back,  we  very  probably  may  have  coexisting  cerebral  menin- 
gitis, spinal  meningitis  and  myelitis,  and  the  symptoms  will  be  those 
of  meningitis  or  myelitis,  as  the  one  or  the  other  preponderates. 
Our  patient  finally,  as  the  result  of  nervous  shock  from  an  injury  to 
his  back,  may  escape  organic  trouble  but  develop  spinal  ansemia 
and  marked  hysteria,  lasting  many  months.  Meningo-myelitis  is  a 
very  grave  disease,  and  one  which  devitalizes  the  whole  system.  If 
our  patient  recovers,  he  is  probably  a  broken-down  man,  and  we 
must  hereafter  keep  him  on  cod-liver  oil,  phosphorus,  arsenic  and 
bichloride  of  mercury,  with  electricity  to  improve  his  general  nu- 
trition. A  patient  who  has  had  a  spinal  injury,  may  have  his 
vision  very  materially  impaired.  There  may  be  a  weakness  of  sight, 
an  intolerance  of  light,  double  vision,  amblyopia,  paralysis  of  ac- 
commodation, and  anomalies  of  refraction. 

These  optic  lesions  are  due  to  extension  of  meningeal  trouble  to 
the  cerebrum.  If  the  brain  is  unaffected  the  impairment  of  sight  may 
be  due  to  the  action  of  the  sympathetic  nerves.  The  filaments  of  the 
sympathetic  that  supply  the  eye  take'  their  origin  from  that  part  of 
the  spinal  cord  which  is  contiguous  to  the  origin  of  the  first  pair  of 
dorsal  nerves,  and  the  portion  of  the  cord  which  extends  from  the 


6 14  PSYCHOLOGICAL    MEDICINE. 

fifth  cervical  to  the  sixth  dorsal  vertebra  possesses  a  distinct  influ- 
ence on  the  eyes  and  vision.  I  consider  it  certain,  therefore,  that  we 
get  an  affection  of  the  optic  disc  and  its  vicinity  from  the  various 
disturbances  of  the  spine  consequent  upon  injuries  to  the  back.  These 
optic  lesions  are  principally  due  to  a  cerebral  meningitis  that  com- 
menced as  a  spinal  meningitis.  We  have  perverted,  impaired,  or  lost 
sensibility  of  tlie  optic  nervous  tract  as  the  result  of  spinal  concus- 
sion, with  atrophy  of  the  optic  disc  as  the  final  stage.  Where  the 
brain  is  unaffected,  the  loss  of  sight  is  due  therefore  to  the  transmis- 
sion of  the  morbid  action  from  the  cord  to  the  vessels  of  the  eye 
by  the  agency  of  the  sympathetic  nerve,  rather  than  by  extension  of 
inflammation. 

The  medico-legal  aspect  of  a  case  where  there  has  been  a  severe 
injury  to  the  back,  causing  concussion  of  the  spine,  should  be  stated 
by  the  physician  who  is  applied  to  for  information,  very  decidedly, 
but  briefly.  Our  patient's  mental  and  physical  vigor  are  gone,  and 
if  the  changes  have  been  organic  in  the  cord  and  brain,  gone  probably 
forever.  He  never  can  be  the  same  man  as  before  the  injury.  Death 
is  far  preferable  to  a  life  of  hopeless  invalidism,  as  many  such  patients 
must  ever  after  lead.  The  prognosis  in  these  cases  is  always  very 
grave  if,  after  a  year  or  two  has  elapsed  from  the  time  of  the  occur- 
rence of  the  accident,  the  symptoms  of  meningo-myelitis  either  con- 
tinue to  be  gradually  progressive,  or,  after  an  interval  of  quiescence, 
suddenly  assume  an  increased  activity.  Cases  of  injuries  to  the  back, 
without  apparent  mechanical  lesion,  may  die  ;  first,  at  an  early  period, 
by  the  severity  of  the  direct  injury;  and  second,  at  a  more  remote 
date,  by  the  occurrence  of  inflammation  of  the  cord  and  its  mem- 
branes ;  and  finally,  after  the  lapse  of  several  years,  by  the  slow  and 
progressive  development  of  structural  changes  in  the  cord  and  its 
membranes.  The  patient,  if  he  does  not  die,  may  have  a  mitigation 
of  his  symptoms — an  amelioration — but  a  thorough  cure,  after  severe 
spinal  concussion,  we  shall  never,  or  very  rarely,  witness. 

Our  prognosis  in  these  cases  should  always  be  very  guarded.  The 
chances  are  decidedly  against  our  patient  as  regards  complete  re- 
covery. The  general  health  tends  progressively  to  break  down,  and 
if  our  patient  gets  up  a  chronic  myelitis,  the  chances  are  that  he  will 
die  in  a  few  years.  Those  cases  are  the  most  favorable  in  which  the 
symptoms  attain  their  intensity  soon  afte?'  the  injury,  while  a  long  in- 
terval between  the  receipt  of  the  injury  and  the  development  of  the 
spinal  symptoms  is  unfavorable  to  our  patient's  recovery.    The  treat- 


SPINAL    CONCUSSION — ITS    MEDICO-LEGAL    RELATIONS,    ETC.       615 

ment  is  rest,  counter-irritation,  nerve  sedatives,  and  the  constant  cur- 
rent of  electricity  to  the  spine.  For  a  constitutional  treatment  I 
prefer  iodide  of  potassium,  quinine,  and  bichloride  of  mercury,  with 
cod-liver  oil.  The  constant  current  is  indicated  when  our  patient 
has  developed  a  spinal  anaemia,  and  the  phosphide  of  zinc  and  strych- 
nia are  valuable  also.  In  inflammatory  states  of  the  cord  electricity 
and  strychnia  would  be  contraindicated,  while  ice-bags  and  ergot 
would  do  good.  We  must  give  our  patient  cheerful  surroundings, 
and  build  him  up  physically  and  mentally,  and  in  exceptional  in- 
stances we  may  see  complete  recovery. 

In  conclusion,  i.  It  is  important,  from  a  medico-legal  point  of 
view,  to  remember  that  from  an  injury  to  the  back  we  may  have  un- 
suspected fractures  of  some  of  the  vertebrae  ;  and  that,  although  there 
may  be  no  head  symptoms  and  no  head  injury,  and  no  paralysis,  yet 
the  injury  inflicted  may  be  of  a  fatal  nature,  although  life  maybe  pro- 
longed for  several  days  until  death  occurs  from  some  accidental 
movement. 

2.  We  may  also  have  injuries  to  the  back  or  spine  occurring  that 
are  necessarily  fatal,  without  any  direct  blow  on  the  spine,  but  from 
falls  on  the  head.  We  may  get  an  inflammatory  softening  and  dis- 
integration of  the  cord  in  such  cases. 

3.  We  may  have  many  diverse  kinds  or  varieties  in  the  extent  and 
degree  of  paralysis  of  motion  and  sensation.  Of  course  the  symp- 
toms in  any  given  case  will  be  varied  in  character  and  extent,  ac- 
cording to  the  location  of  the  injury,  the  force  with  which  it  has  been 
inflicted,  and  the  amount  of  organic  lesion  that  the  delicate  sub- 
stance of  the  spinal  cord  has  suffered  from  by  the  shock  or  jar  that 
has  been  inflicted  upon  it. 

4.  We  may  have  a  severe  contusion,  with  paraplegia  and  an  un- 
suspected laceration  of  the  intervertebral  ligaments,  followed  by  death 
in  a  few  days. 

5.  We  may  have  a  slowly  developed  spinal  meningitis  from  a  direct 
injury  to  the  back  in  railway  collisions,  terminating  eventually  in 
death. 

6.  We  may  have  a  direct  injury  to  the  back  and  slow  development 
of  paralytic  symptoms. 

7.  We  may  have  compression  and  concussion  of  the  cervical  spine 
from  a  blow  on  the  head,  with  paraplegia  and  a  slow  recovery. 

8.  We  may  have  falls  from  horseback,  or  from  carriage  accidents, 


6x6  PSYCHOLOGICAL    MEDICINE. 

with  concussion  of  the  spine,  immediate  paralysis  and  complete  re- 
covery. 

9.  We  may  have  a  direct  injury  to  the  back,  without  apparent  me- 
chanical lesion,  followed  by  a  paralysis  of  one  limb  only. 

10.  We  may  have  a  concussion  of  the  spine  from  falls  on  the  back, 
followed  by  partial  paralysis  of  sensation  and  motion  of  the  lower 
limbs,  without  affection  of  the  sphincters,  and  terminating  in  incom- 
plete recovery. 

11.  We  may  have  falls  on  the  back,  with  partial  paraplegia  and 
recovery. 

12.  We  may  have  cases  of  slight  injury  to  the  head  or  back,  fol- 
lowed by  serious,  persistent,  or  fatal  results. 

13.  We  may  have  epilepsy,  appearing  by  transmission  in  children, 
whose  parents  have  become  epileptic  hy  an  injury  to  the  spinal  cord. 

14.  We  may  have  hyperaesthesia,  anaesthesia,  pain,  and  perverted 
sensations  of  all  sorts  and  kinds  in  cases  of  spinal  concussion  from 
injuries  to  the  back. 

15.  After  an  injuiy  to  the  back  we  may  have  complete  recovery, 
incomplete  recovery,  permanent  disease  of  the  spinal  cord,  and  men- 
ingitis ;  or,  finally,  death. 

16  We  may  have  a  terrible  nervous  shock  resulting  from  injuries 
to  the  back,  no  immediate  effects,  a  chronic  meningitis  of  the  cord 
and  base  of  the  brain,  and  an  imperfect  recovery. 

17.  We  may  have  a  violent  fall,  with  no  injury  externally  apparent 
on  the  back  or  head,  in  which  the  patient  is  much  shaken,  develops 
symptoms  of  concussion  of  the  spine,  and  makes  a  very  slow  recovery. 

18.  These  general  shocks,  with  symptoms  of  spinal  concussion 
and  meningitis,  are  generally  the  result  of  a  railway  collision. 

19.  We  may  have  sprains  or  violent  wrenches  of  the  back  or  spine, 
followed  by  every  variety  of  harm  to  the  spinal  column,  ligaments, 
the  cord,  or  its  membranes. 

During  the  past  summer  I  had  under  treatment  a  case  of  meningo- 
myelitis,  the  result  of  a  blow  on  the  spine  received,  so  far  as  we 
could  tell,  some  months  previous.  The  patient  was  a  lady  of  27 
years  of  age,  who  for  some  years  had  been  addicted  to  periodical  in- 
dulgence in  stimulants,  which  had  got  her  tissues  into  the  worst  pos- 
sible state  to  resist  any  injury.  When  I  was  first  called  to  see  her 
her  pupils  were  somewhat  dilated,  the  gait  staggering,  there  was 
confusion  of  mind,  great  irritability,  and  not  a  perfect  understanding 
of  her  condition  and  surroundings.     These  symptoms  increased,  the 


THE   PSYCHOLOGY   OF   CRIME.  617 

bladder  became  affected  so  that  the  catheter  had  to  be  used  thrice 
daily,  the  memory  was  very  defective,  there  was  restless  sleep  with 
nocturnal  delirium,  vision  was  impaired,  and  the  patient  saw  sparks 
and  flashes  of  light,  the  head  was  hot,  and  she  would  awake  out  of 
sleep  greatly  frightened.  Sensation  was  absent  in  both  legs  and,  as 
the  case  progressed,  all  reflex  movements  disappeared.  There  was 
soon  complete  paraplegia,  with  numbness  of  a  distressing  nature. 
There  was  pain  on  pressure  and  on  movement  over  the  lumbar  ver- 
tebra. Alteratives,  and  tonics,  and  rest,  with  counter-irritation,  were 
all  unavailing.  The  examination  of  the  spine  by  the  hot  sponge 
showed  exalted  sensibility  and  pain  at  the  level  of  the  inflammation. 
In  walking,  the  patient,  in  the  first  stages  of  the  disease,  kept  her 
feet  apart  and  straddled,  and  she  had  a  distressing  sensation  as  if  a 
cord  were  tied  tightly  around  the  waist,  and  complained  of  the  same 
sensation  in  the  limbs.  She  also  complained  of  shooting  pains  in 
the  limbs,  and  of  great  coldness  of  the  feet.  She  lost  weight  rapid- 
ly, even  when  eating  well  and  taking  no  exercise.  The  pulse  at 
first  was  slow  and  never  rose  above  120,  and  the  temperature  re- 
mained nearly  normal  until  it  finally  rose  to  106°,  with  an  irregular 
and  intermitting  pulse  of  120.  Upon  close  inquiry  I  could  not  learn 
that  in  this  case  there  had,  since  the  accident  and  the  time  (about 
four  or  six  months)  of  the  supervention  of  the  serious  symptoms, 
been  any  interval,  however  short,  of  complete  health.  The  cerebral 
disturbance  in  this  case,  the  headache,  confusion  of  thought,  loss  of 
memory,  and  defective  vision  were  referable,  I  think,  to  cerebral 
meningitis  and  arachnitis.  This  appeared  to  be  the  result  of  the  in- 
flammation of  the  cord  and  its  membranes  ascending  so  as  to  involve 
the  intracranial  organs. 


CHAPTER  XXXII. 

THE    PSYCHOLOGY    OF    CRIME. 


Perhaps  there  is  no  question  which  interests  physicians  and  jurists 
alike  more  than  does  the  question  of  the  degree  of  responsibility 
which  attaches  to  the  class  of  the  mentally  unsound  who,  "  laboring 
under  the  tyranny  of  a  bad  organization,"  are  constantly  or  periodi- 


6l8  PSYCHOLOGICAL    MEDICINE. 

cally  impelled  to  commit  crime.  This,  as  we  shall  prove  further  by 
the  admirable  researches  of  the  distinguished  Professor  Moriz  Bene- 
dikt,  of  Germany,  is  the  result  of  a  pathological  state  of  the  brain, 
connected  with  a  peculiar  type  of  skull  development  (shortening  of 
the  occiput,  anterior  vertex  steepness,  "  scheitelsteilheit,"  and  then,  in 
decreasing  progression  in  the  asymmetry  and  the  flattening  of  the 
occiput).  Examination  of  the  brains  of  murderers  after  death  sup- 
port these  facts.  There  is  a  resemblance  to  the  brute  in  some  of 
these  brains,  in  that  the  cerebellum  is  not  covered  by  the  occipital 
lobes  and  that  there  is  also  a  deficient  development.  The  insane,  as 
a  rule,  never  exhibit  remorse  or  feeling  of  guilt  for  crimes  committed. 
This  is  a  well-known  psychological  truth.  It  is  a  fact  not  so  well 
known,  but  which  is  supported  by  the  assertions  of  Benedikt  and 
Holtzendorff,  that  great  criminals  also  rarely  are  penetrated  by  a  feel- 
ing of  their  guilt  or  exhibit  remorse.  If  they  do,  it  is  only  tempo- 
rary. The  psychological  state  of  criminals  who  exhibit  the  anterior 
vertex  steepness  is  the  analogue  of  recurrent  mania  or  of  chronic 
mania  with  lucid  intervals.  It  is  also  analogous  to  states  of  disease 
in  which  attacks  of  illness  of  more  or  less  short  duration  alter- 
nate with  more  or  less  long,  and  generally  for  a  time  prepon- 
derant healthy  intermissions.  They  relapse  periodically  into  crime, 
and,  they  all  unanimously  testif}^,  from  an  irresistible  impulse.  I 
have  a  patient  belonging  to  an  old  and  good  family  who  is  thus 
ethically  degenerate,  in  marked  contrast  to  all  the  rest  of  the  family. 
His  history  is  that,  when  a  child,  he  would  lie  about  everything  with 
apparently  no  reason,  would  not  take  a  healthy  normal  interest  in 
the  sports  of  boyhood,  but  was  very  lazy ;  did  not  like  to  study,  and, 
when  older,  would  not  work  ;  never  drank,  but  was  addicted  to  self- 
abuse.  When  older,  he  wandered  aimlessly  from  place  to  place, 
generally  making  himself  so  obnoxious  by  his  foolish  conduct  that 
he  shortly  wore  out  his  welcome. 

Upon  coming  under  our  care  we  discovered  at  once  the  peculiar 
criminal  skull  formation  and  observed  that  he  was,  like  the  insane, 
much  affected  by  barometrical  states,  and  especially  by  thunder- 
storms. He  seemed  to  be  ethically  degenerate,  and  there  was  a  moral 
imbecility  in  his  case  which  was  probably  congenital.  He  repeat- 
edly has  told  me  that  he  felt  afraid  of  himself  and  acknowledged  that 
he  had  criminal  impulses,  but  would  not  state  explicitly  in  what  di- 
rection they  lay.  He  claimed  that  these  impulses  occurred  only  at 
times,  and  that  they  were   irresistible.     Such   cases   are  incurable 


THE    PSYCHOLOGY    OF    CRIME.  6\g 

when  congenital,  and  if  all  of  them  could  be  sent  to  an  asylum  for 
the  chronic  insane  for  life  much  harm  would  be  saved  to  the  com- 
munity, many  crimes  would  not  be  committed,  and  punishment  by 
death  could,  as  Holtzendorff  and  Benedikt  have  shown,  be  practically 
done  away  with.  Relapses  are  absolutely  certain  in  these  cases,  be- 
cause the  brain  is  abnormally  developed.  If  we  could  examine  such 
a  brain  we  should  find  an  abnormal  prominence,  and  also  a  prepon- 
derance of  the  fissures,  which  is  a  sign  of  arrested  development,  for, 
as  Professor  Benedikt  has  shown,  this  condition  arises  from  the  cir- 
cumstance that  certain  convolutions  remain  stationary  in  the  deep 
parts,  and  have  therefore  not  arrived  at  their  full  development  or 
have  not  developed  themselves.  We  might  also  find  that  the  cere- 
bellum was  not  covered  by  the  occipital  lobes  of  the  brain,  as  it  nor- 
mally is.  Professor  Benedikt  found  this  in  three  brains  of  murderers 
which  he  examined  post  mortem,  and  in  a  fourth  case  an  equivalent 
condition  was  observed  b}^  him. 

In  an  address  of  Professor  Benedikt's  before  the  meeting  of  the  Ju- 
ridical Society  of  Vienna,  December  28th,  1875,  he  exhibited  some 
varieties  of  skull  formation  which  play  a  great  part  in  the  natural 
history  of  crime,  and  spoke  as  follows  concerning  them  :  "If  in  the 
normal  skull,  in  a  straight  line  from  before  backwards,  the  distance 
is  measured  from  the  fossa  behind  the  auditory  foramen  to  the  most 
posterior  eminence  of  the  occiput,  it  will  be  found  to  amount  to  two- 
fifths  and  more  of  the  straight  line  drawn  from  before  backwards, 
in  the  middle  line  between  the  forehead  and  the  summit  of  the  occi- 
put (the  sagittal  diameter).  I  show  you  now  that  in  other  skulls  this 
is  not  the  case,  inasmuch  as  the  first  line  reaches  one-third,  or  one- 
fourth,  or  less  of  the  second.  I  call  this  '  brachycephalia  occipitalis.' 
In  the  second  place  I  show  you  that  the  difference  in  height  between 
the  highest  point  of  the  forehead  and  the  crown  of  the  head  is  but 
small  {i}4  centimetre).  In  many  skulls  the  difference  is  consider- 
able (as  much  as  7  centimetres),  and  this  proportion  I  call  '  anterior 
vertex  steepness.'  " 

Scheitelsteilheit. — A  further  variety  is  the  asymmetry  of  the  two 
halves  of  the  skull ;  and,  lastly,  please  to  observe  the  form  of  the 
posterior  surface ;  it  is  in  certain  skulls  very  flat,  while  in  others  this 
occipital  flatness  is  wanting. 

The  professional  robber,  Professor  Benedikt  thinks,  is  affected 
with  ethical  idiocy. 

Covetousness,  ethical  weakness  of  mind,  pleasure  in  the  imaginary 


620  PSYCHOLOGICAL    MEDICINE. 

or  actual  conviction  of  obtaining  the  desired  means  of  existence 
without  work,  when  mental  or  bodily  power  is  deficient,  or  the  dislike 
of  taking  this  power  any  longer  into  account,  are  the  factors,  he  says, 
out  of  which  the  psychological  product  of  assassination  for  the  love 
of  gain  is  composed. 

Violence  of  temperament,  continuance  of  a  strongly-excited  dis- 
like, overweening  feeling  of  power  and  of  pleasure  in  exercising 
strength  over  relative  weakness  of  intellect,  and  want  of  ethical  de- 
velopment form  the  psychological  basis  of  rough  manslaughter,  he 
says,  as  well  as  of  murder  from  revenge  with  slight  motives.  The 
psychology  of  theft  he  describes  as  excessive  pleasure  in  revelling 
and  disgust  for  work,  which  form  the  peculiar  basis  of  the  ordinary 
thief's  nature.  These  are  the  impulses,  he  says,  which  cause  the 
consciousness  of  the  balance  between  meum  and  tuum  to  be  dis- 
turbed and  finally  to  disappear  altogether.  The  kleptomania  of 
hysterical  persons  he  speaks  of  as  worthy  of  observation,  in  whom 
there  is  an  impulse  to  possess  everything  without  making  use  of  it. 
Benedikt  says  that  the  whole  psychological  I  is  affected  in  the  thief, 
but  the  ethical  and  the  motor  I,  and  the  intellectual,  in  a  more  limited 
sense.  He  speaks  of  the  special  banknote  forger  as  belonging  to  that 
type  of  criminals  who  very  generally  relapse,  and  very  truly  says  that 
the  same  prominent  characteristic  feature  of  motive  ingenuity  will 
protect  a  man  from  the  path  of  crime  if  he  has  the  talent  of  concep- 
tion and  the  spirit  of  origination,  or  if  a  developed  ethical  talent  is 
present  in  his  disposition.  The  knowledge  of  the  complicated  nature 
of  the  psychology  of  crimes  is,  however,  extraordinarily  important, 
says  Benedikt,  in  the  question  of  the  degree  of  punishment  to  be 
awarded  and  of  the  possibility  of  amendment.  When  anyone  with  a 
fierce  temperament  and  an  arrogant  consciousness  of  strength  has 
been  mentally  ill-developed,  has  learned  onh^  the  roughest  hand 
labor,  and  has  not  been  educated  in  morals,  he  may  become  a  useful 
member  of  society  if  his  intellect  and  his  cleverness  are  developed 
and  the  slumbering  better  feelings  are  awakened.  Then  is  the  indi- 
vidual, he  says,  further  developed,  and  the  restraints  which  were  for- 
merly wanting  may  now  come  into  activity.  When  the  conditions 
are  of  this  nature  that  from  the  impulses  leading  to  crime  there  is  no 
dissuasion  and  to  those  restraining  from  it  there  is  no  persuasion, 
there  is  no  chance  of  improvement,  and  legislative  punishment  be- 
comes stronger  and  stronger  for  habitual  criminals.  There  is  then, 
Benedikt  says,  no  advantage  in  setting  such  a  criminal  free,  for  he 


THE    PSYCHOLOGY   OF    CRIME.  62 1 

will  again  commit  crime.  If  we  now  make  an  inquiry  on  the  ground 
of  these  empirical  experiences  and  their  analysis,  in  order  to  find 
whether,  in  a  certain  percentage  of  certain  grades  and  categories  of 
crimes,  certain  changes  cannot  be  detected  in  the  brain  or  the  skull, 
we  shall  find  that  we  do  not  need  to  seek,  as  the  old  doctrine  of  Gall 
attempted  to  do,  for  the  foundation  of  crime  in  altogether  local  de- 
velopmental alterations,  but  that  excesses  and  defects  of  constitution 
and  development  must  be  present  in  the  three  great  centres  of  ideas, 
of  motion,  and  of  sensation.  Benedikt  further  says  that  we  must  not 
assume,  because  characteristic  changes  are  present  in  criminal  na- 
tures, that  men  so  constituted  must  necessarily  commit  crime.  The 
question  here,  he  says,  is  only  as  to  a  predisposition,  just  as  persons 
with  a  narrow  chest  have  a  predisposition  to  tuberculosis  or  children 
of  insane  parents  have  an  insane  diathesis.  It  must  always  depend, 
he  says,  on  a  number  of  conditions  whether  a  nature  predisposed  to 
crime  will  actually  become  a  criminal,  and  the  clearer  we  are  as  to 
the  psychological  and  anthropological  marks  by  which  the  disposi- 
tion may  be  revealed,  the  more  surely  shall  we  prevent  crime  by 
education  and  watchfulness.  The  numerical  results  of  the  examina- 
tion of  a  large  number  of  heads  show  that  "  bracliyceplialia  occipitalis" 
while  wanting  in  93.5  of  normal  skulls,  is  wanting  in  only  23  per  cent, 
of  robber-murderers  and  45  per  cent,  of  murderers  from  motives. 
It  is  great  in  only  2  per  cent,  of  normal  skulls. 

Occipital  flatness  is  wanting  in  58  per  cent,  of  normal  skulls,  in 
only  16  per  cent,  of  the  heads  of  robber-murderers,  and  in  28  per 
cent,  of  the  heads  of  murderers  from  motives.  It  is  well  marked  in 
only  12  per  cent,  of  normal  skulls,  and  in  59  per  cent,  of  the  heads 
of  robber-murderers.  Asymmetry  is  wanting  in  62  per  cent,  of 
normal  heads,  in  only  10  per  cent,  of  the  heads  of  robber-murderers, 
and  in  25  per  cent,  of  the  heads  of  murderers  from  motives.  It  is 
great  in  only  13  per  cent,  of  normal  heads,  in  43  per  cent,  of  the 
heads  of  thieves,  and  in  32  per  cent,  of  the  heads  of  murderers. 

Vertex  steepness  is  wanting  in  85.2  per  cent,  of  normal  heads,  and 
in  only  40  per  cent,  of  the  heads  of  thieves.  Professor  Benedikt 
says,  that  wherever  abnormalities  occur  in  a  high  degree  and  in  com- 
bination, there  exists  a  relapse  into  an  earlier  stage  of  the  develop- 
ment of  mankind,  and  the  examinations  of  brains  confirm  this  view. 

The  late  Dr.  Ray,  who  was  an  eminent  alienist,  said  :  "  Let  me  also 
say  that  the  moral  pathology  to  be  learned  in  these  establishments 
(institutions  for  the  cure  of  mental  diseases)  will  have  an  important 


622  PSYCHOLOGICAL    MEDICINE. 

bearing  on  some  of  the  prominent  questions  of  moral  and  social 
science.  If  we  are  ever  to  obtain  a  correct  theory  of  human  conduct, 
to  discover,  in  any  degree,  the  secret  springs  of  action,  or  to  pene- 
trate into  the  mysteries  of  human  delinquency,  it  must  be  by  the 
study  of  morbid  psychology  in  that  broad  and  liberal  manner  which 
is  possible  only  amid  large  collections  of  the  insane.  No  one  who 
declines  to  receive  his  opinions  on  trust  can  help  being  embarrassed 
by  the  problems  presented  by  many  an  historical  name,  or  those 
revelations  of  character  so  often  found  on  the  records  of  our  courts. 
We  seek  in  vain  for  any  light  on  the  questions  thus  raised,  and  are 
obliged  to  rest  helplessly  in  the  conviction  that  there  are  more  things 
in  heaven  and  earth  than  are  dreamt  of  in  our  philosophies.  Indeed, 
these  difficulties  cannot  be  overcome  by  any  theories  of  human  con- 
duct which  suppose  the  mind  to  be  in  a  perfectly  normal  condition. 
They  point  to  imperfection,  or  deficiency,  or  obliquity,  the  result  of 
organic  influences,  and  they  can  be  cleared  up  in  no  degree  except 
by  the  profound  study  of  organic  conditions  in  connection  with  ab- 
normal mental  phenomena.  From  this  kind  of  study  we  may  justly 
expect  that  a  light  will  be  thrown  on  the  field  of  history  and  biog- 
raphy, by  which  many  of  their  pages  will  be  read  with  sentiments 
very  different  from  those  which  they  now  inspire.  It  would  show 
us  that  much  of  what  the  world  calls  genius  is  the  result  of  a  morbid 
organic  activity;  that  many  a  saint,  or  hero,  or  martyr,  became  such 
more  by  virtue  of  a  peculiar  temperament  than  of  a  profound  sense 
of  moral  or  religious  obligation;  that  the  horrible  crimes  which  have 
imparted  an  infamous  distinction  to  the  Tiberiuses  and  Caligulas  of 
history  proceeded  rather  from  cerebral  disorder  than  a  native  thirst 
for  blood." 

Dr.  Ray  says  elsewhere:  "The  researches  of  Gall  and  Spurzheim 
first  led  to  more  philosophical  views  respecting  the  constitution  of 
the  brain,  for  although  their  system  has  failed  to  obtain  any  consid- 
erable belief,  yet  their  particular  proposition,  that  size  is  a  measure 
of  power,  will  scarcely  be  disputed  now.  The  next  step,  of  little  less 
importance,  was  made  by  their  followers  in  explaining  the  apparent 
exceptions  to  the  rule,  by  supposing  a  diversity  of  quality  in  the 
materials  of  which  the  brain  is  composed.  At  a  later  period,  the 
deteriorating  influences  of  vicious  or  unhealthy  habits  and  usages 
were  made  the  subject  of  an  admirable  work  by  Morel,  while  the 
effect  of  nervous  disorders  on  the  cerebral  organism  was  investigated 
by  Moreau  de  Tours  with  remarkable  acuteness.     The  result  of  these 


THE    PSYCHOLOGY   OF   CRIME.  623 

and  other  kindred  inquiries  was  to  establish  beyond  a  reasonable 
doubt  the  principle,  that  the  brain  comes  into  the  world  with  the 
same  imperfections  and  deficiencies,  the  same  irresistible  tendencies 
to  disease  or  perversity  of  action,  which  have  long  been  observed  in 
regard  to  other  organs.  Thus  was  opened  a  new  realm  of  inquiry, 
of  unprecedented  interest  to  the  student  of  pathological  psychology, 
and  of  immense  importance  in  many  practical  relations  of  life.  We 
have  as  yet  but  a  faint  idea  of  its  full  significance,  but  it  needs  no 
great  faith  to  believe  that  it  is  destined  to  modify  very  much  our 
present  theories  of  human  action,  and  throw  new  light  on  many  dark 
problems  of  human  conduct.  Recent  investigations  have  added  new 
difficulties  to  a  subject  already  regarded  with  much  diversity  of 
opinion.  If  overt  disease,  manifested  by  appreciable  symptoms  during 
life  and  various  lesions  after  death,  can  annul  responsibility,  the 
question  inevitably  follows,  luhether  that  cerebral  condition, — neither 
of  health  nor  of  disease,  as  those  terms  are  usually  understood, — which 
is  produced  by  tendencies  to  disease  or  ancestral  vices,  may  not  impair 
it,  in  some  degree,  under  some  circumstances  ?^  This  is  the  question 
of  questions  presented  to  the  psychologists  of  our  times,  and  des- 
tined, undoubtedly,  to  raise  sharper  conflicts  than  any  other  in  the 
whole  range  of  medical  jurisprudence.  It  is  involved  in  obscurity, 
it  is  met  by  the  bitter  prejudices  of  those  who  lead  public  opinion, 
and  extensive  investigations  and  various  knowledge  are  needed  for 
its  solution." 

A  grave  moral  impropriety,  the  result  of  criminal  impulses,  is 
popularly  called  wickedness.  A  grave  intellectual  impropriety  often 
indicates,  to  even  a  casual  observer,  unequivocal  insanity,  and  is 
attributed  to  mental  defect.  Both  may  be  equally  the  mental  mani- 
festations of  imperfection,  congenital  defect,  or  abnormal  depreciation 
of  the  cerebral  system.  The  best  proof  of  this  is,  that  insanity  and 
crime  may  both  appear  either  in  the  same  generation  or  in  different 
generations  of  the  same  family.  This  is  a  well-known  fact.  "To 
say,"  says  Dr.  Ray,  "that  a  man's  character  and  conduct  are  deter- 
mined, in  a  great  degree,  by  the  original  constitution  of  his  brain 
and  nervous  system,  is  to  utter  a  truth  that  can  hardly  be  called  new. 
Few,  however,  are  disposed  to  make  any  proper  account  of  those 
cerebral  qualities  which  imply  a  deviation  of  some  kind  or  other  from 
the  line  of  healthy  action.  It  is  not  in  accordance  with  the  philosophy 
of  our  times  to  see  in  them  an  explanation  of  these  strange  and 

*  Italics  are  mine. 


624  PSYCHOLOGICAL   MEDICINE. 

curious  traits  which  are  utterly  inexplicable  on  the  principles  that 
govern  the  conduct  of  ordinary  men.  How,  then,  could  they  expect 
the  popular  approbation  who  find  in  them  a  clue  to  some  of  the 
mysteries  of  human  delinquency?  But  the  teachings  of  science,  the 
stern  facts  of  observation,  cannot  be  disregarded.  Whether  we  ignore 
them  or  not,  sooner  or  later  their  full  significance  will  be  triumphantly 
acknowledged.  In  the  popular  apprehension,  even  downright  insanity 
is  regarded  as  of  little  practical  account,  unless  it  courts  observation 
by  the  force  and  variety  of  its  manifestations.  Only  its  more  demon- 
strative forms  are  supposed  to  be  capable  of  affecting  the  legal  re- 
sponsibility of  men.  The  world  is  reluctant  to  believe  that  a  person, 
who,  in  most  respects,  is  rational  and  observant  of  the  ordinary  pro- 
prieties of  life,  can  be  so  completely  under  the  influence  of  disease 
as  to  be  irresponsible  for  any  of  his  acts.  If  the  world  is  reluctant 
to  allow  to  this  class  of  persons  the  immunities  of  insanity,  it  could 
hardly  be  expected  to  treat,  with  any  degree  of  favor,  those  traits  or 
conditions  of  mind  which  imply  not  disease,  perhaps,  but  abnormal 
imperfection  of  the  brain.  And  yet  it  cannot  be  denied  that  the 
course  of  thought,  the  sense  of  moral  distinctions,  the  actual  con- 
duct, may  be  greatly  affected  by  the  influence  of  such  imperfection. 
Are  we  not  bound,  then,  by  a  sense  of  justice  and  the  claims  of 
science,  to  make  some  account  of  it  in  forming  our  estimates  of  char- 
acter and  fixing  the  limits  of  responsibility?  Can  we  do  otherwise 
without  the  greatest  inconsistency?  Knowing  that  an  individual  is 
descended  from  a  line  of  progenitors  abounding  in  every  form,  of 
nervous  disorders,  shall  we  think  it  strange  that  some  vestige  thereof 
should  have  come  to  him  ?  And  knowing  that  the  qualit}'-  of  the 
brain  is  necessarily  affected  by  such  disorder,  shall  we  not  seek,  in 
this  fact,  for  an  explanation  of  what  would  be  inexplicable  upon  any 
ordinary  principles  of  human  conduct?" 

If  there  is  a  tendency  to  disease,  not  disease  itself  in  any  particular 
brain,  the  accumulated  results  of  experience  of  many  able  observers 
all  tend  to  show  that, —  ist,  it  may  die  out;  2d,  that  it  may  manifest 
itself  in  all  forms  of  nervous  diseases  up  to  fully  developed  mania; 
or,  3d,  that  it  may  show  itself  in  inebriety  or  a  proclivity  to  crime. 
The  offspring  of  insane  parents  may  be  insane,  inebriates,  or  crimi- 
nals. The  moral  sentiments  are  just  as  apt  to  be  affected  by  cerebral 
defect  as  is  the  purely  intellectual  part  of  our  nature.  It  may  be 
mental  capacity  and  vigor,  or  it  may  be  moral  capacity  and  vigor, 
which  is  attacked  by  disease  in  any  given  case.     Given,  a  latent  ten- 


I 


THE    PSYCHOLOGY    OF    CRIME.  625 

dency  to  disease  from  congenital  or  acquired  vices  of  cerebral  con- 
formation or  nutrition,  and  no  psychologist  or  alienist  can  predicate 
with  any  certainty  whether  the  fully  formed,  fully  developed  attack 
will  fall  on  the  purely  intellectual  or  on  the  moral  side  of  a  man's 
nature.  A  great  criminal  or  a  raving  maniac  may  be  the  result  of 
the  evolution  of  the  morbid  psychic  force.  How  can  we  as  far  as 
possible  antagonize  these  latent  tendencies  if  we  suspect  them  to 
exist?  I  would  answer,  by  a  good  physical  education  and  a  sound 
mental  discipline,  to  strengthen  the  powers  of  the  mind  and  keep 
them  in  healthy  channels  of  thought,  feeling,  and  action.  In  deciding 
between  depravity  and  mental  infirmity,  we  must  remember  that 
embryonic  mental  disease  may  leap  into  sudden  and  overpowering 
activity  with  just  as  little  warning  as  a  stroke  of  paralysis  may  result 
from  a  family  tendency  to  it,  and  that  an  appalling  crime  or  an  attack 
of  furious  mania  may  follow  close  on  a  short  initiatory  period  of 
depression  of  spirits.  There  are  cases  of  incurable  chronic  insanity 
familiar  to  every  alienist,  where  there  are  lucid  intervals  simulating 
recovery,  where  there  is  a  resumption  of  apparently  perfectly  healthy 
mental  action.  A  casual  observer  would  say  the  person  was  perfectly 
sane.  The  disease,  however,  from  what  cause  we  know  not,  is  merely 
latent,  and  we  have  personally  seen  the  most  terrific  burst  of  mania 
following,  with  no  warning  save  that  of  one  sleepless  night,  a  mental 
calm  so  deceptive  that  it  appeared  like  perfect  sanity.  Just  so  in  the 
criminal,  the  impulse  lies  in  embryo,  strictly  in  accordance  with  the 
laws  of  morbid  action  as  evinced  in  mental  disease,  and  we  cannot 
tell  what  will  be  the  mode  of  its  operation.  We  do  know  that,  owing 
to  cerebral  defect,  it  will  recur  quite  regularly,  and  it  seems  hardly 
just  to  release  a  criminal  who  must,  from  the  very  nature  of  things, 
commit  fresh  crimes,  and  then  take  his  life  by  capital  punishment 
when  his  cerebral  conformation  would  suggest  that  an  asylum  for 
the  criminal  insane  for  life  would  be  the  appropriate  place  for  him. 
The  Townley  case  in  England,  some  years  ago,  is  an  instance  of  an 
appalling  crime  being  committed  by  one  inheriting  a  tendency  to 
insanity,  where  great  injustice  was  done  and  humanity  and  science 
lost  sight  of,  because  the  public  deprecated  any  judicial  mercy,  and 
penal  servitude  for  life  in  Australia,  with  the  subsequent  suicide  of 
the  prisoner,  completed  the  history  of  the  unfortunate  young  man. 

The  facts  of  criminal  psychology,  Professor  Benedikt  has  shown 
us,  lead  us  to  regard  the  impulse  of  criminal  natures  in  the  light  of 
natural  laws,  and  to  believe  that  a  deficient  organization  occasions 

40 


02D  PSYCHOLOGICAL   MEDICINE. 

the  disposition  to  an  abnormal  moral  constitution.  In  all  four  of  the 
brains  of  murderers  which  Professor  Benedikt  examined,  it  was  found 
that  there  existed  a  deficient  anthropological  development,  and  in  all 
four  cases  sentence  of  death  was  passed  on  the  ground  o^the  exist- 
ence of  a  full  responsibility  recognized  by  judges  and  medical  men. 
The  existence  of  cerebral  abnormities  was  in  each  case  the  cause  of 
the  criminal  impulse.  Unhealthy  psychical  function  means  generally, 
if  not  always,  either  a  congenital  or  an  acquired  vice  of  conformation 
or  nutrition  of  the  cerebral  system,  and  this  fact  should  warn  judges 
and  juries  to  exercise  great  caution. 

Professor   Benedikt   gives   the    description  of  the  brains  of  two 
murderers  who  committed  a  murder  for  hire  : 

In  one,  the  cerebellum  is  not  covered  by  the  occipital  lobes,  and  the  occipital  brachy- 
cephalia  is  present  on  the  left  side.  In  the  right  hemisphere  the  ascending  posterior  spur 
is  merged  with  the  ascending  part  of  the  interparietal  fissure,  and  reaches  at  the  median 
surface  into  the  gyrus  fornicatus.  The  second  parietal  lobe  is  divided  from  the  first  tem- 
poral lobe  by  a  long  fissure  (parieto-temporal  fissure)  which  is  lost  in  an  operculum  with 
plis  de passage  (parieto-temporal  operculum),  which  is  bounded  by  the  lobulus  tuberis 
and  by  lobules  which  are  probably  to  be  regarded  as  processes  of  the  first  and  second 
temporal  lobes,  but  are  pretty  clearly  distinguished  from  them.  The  ill-developed  gyri 
fusiformes  and  lingualis  rise  upwards  steeply  from  the  plane  of  the  gyrus  uncinatus  to- 
wards the  summit  of  the  occiput,  and  thereby,  that  the  fissura  calcarina  may  reach  to  the 
same  point,  is  the  gyrus  rectus  of  the  occiput  reduced  to  a  minimum.  The  vertical  occipital 
fissure  is  in  direct  communication  on  the  one  hand  with  the  horizontal  occipital  fissure,  and 
on  the  other  hand  with  the  sulcus  hippocampi.  The  horizontal  occipital  fissure  exhibits 
the  ape-form  with  its  plis  de  passage.  The  first  three  temporal  convolutions  are  arranged 
concentrically  according  to  the  brute  type,  with  the  concavity  downwards.  The  gyrus 
uncinatus  and  gyrus  hippocampi  are  very  deficient  in  convolutions.  The  fissura  prsecen- 
tralis  reaches  to  the  middle  border.  (The  first  and  second  frontal  fissures  are  divided 
from  it  by  imperfect  convolutions.)  Plis  de  passage  are  found  both  in  the  horizontal  oc- 
cipital fissure  and  in  the  parieto-temporal  operculum,  in  the  posterior  spur  of  the  fissure 
of  the  fossa  Sylvii  combined  with  the  interparietal  fissure,  in  the  anterior  ascending  spur 
of  the  same  fissure,  and  also  in  all  the  furrows.  On  the  left,  the  posterior  ascending  spur 
of  the  fissure  of  the  fossa  Sylvii  rises  to  the  median  line,  and  the  interparietal  and  pa- 
rieto-temporal fissures  are  separated  from  it  by  ill-developed  portions  of  convolutions. 
The  vertical  occipital  fissure  is  not  connected  with  the  interparietal  fissure.  The  second 
frontal  convolution  in  crossed  with  the  fissura  prsecentralis,  and  thereby  are  the  first  and 
second  frontal  convolutions  divided  into  (smaller)  posterior  and  (larger)  anterior  halves. 
The  fissura  pi-secentralis  reaches  as  far  as  the  inferior  border,  and  is  excessively  convo- 
luted. The  first  and  second  temporal  furrows  are  arranged  in  a  more  normal  manner.  In 
other  respects  the  arrangement  is  the  same  as  on  the  right. 

In  the  second  brain,  the  body  of  the  organ  appeared,  on  the  other  hand,  altogether 
oblique  and  shortened,  and  the  obliquely  situated  cerebellum  was  deeply  imbedded  in 
the  niche  of  the  fourth  and  fifth  temporal  convolutions,  whereby  the  mass  of  the  occiput 
appeared  to  be  deteriorated  in  a  high  degree  behind  the  gyrus  uncinatus.  On  the  right, 
he   posterior  spur  of  the  fissure  of  the  fossa  Sylvii  rises  high  up,  but  without  reaching 


THE    PSYCHOLOGY    OF    CRIME.  ^IJ 

the  median  border.  The  interparietal  fissure  is  in  normal  proportion  with  it,  but  stands, 
nevertheless,  in  direct  communication  with  the  fissura  Rolandi.  The  horizontal  occipital 
fissure  shows  no  decided  similarity  to  the  apes.  The  parietq-temporal  fissure  is  not  much 
developed;  the  parieto-temporal  operculum  is  well-marked.  The  first  three  temporal 
fissures,  with  their  convexity  downwards,  concentrically  surrounding  with  a  rim  imper- 
fectly formed  convolutions.  The  fissura  prascentralis  goes  as  far  as  the  median  surface, 
and  contains  an  operculum  in  the  transition  between  the  second  and  third  frontal  convo- 
lutions. The  same  is  found  (between  all  the  three  frontal  convolutions)  in  the  most  an- 
terior part  of  the  first  frontal  furrow.  The  second  frontal  convolution  at  the  base  badly 
developed;  the  fissura  cruciata  showing  a  complicated  operculum.  The  gyri  hippo- 
campi and  uncinatus  strongly  projecting  over  the  frontal  lobes  and  a  little  furrowed.  The 
gyri  fusiformis  and  lingualis  rising  steeply  towards  the  top  of  the  occiput,  much  dimin- 
ished, and  especially  the  first  very  much  shortened  by  the  first  two  temporal  convolutions, 
and  connected  in  a  peculiar  serpentine  manner  with  the  posterior  combining  part  of  the 
lobulus  tuberis  and  the  second  temporal  lobe  at  the  parieto-temporal  operculum.  The  per- 
pendicular occipital  fissure  is  connected  with  the  sulcus  hippocampi,  and  conceals  nu- 
merous plis  de  passage.  Especially  the  median  part  of  the  occipital  lobe  reduced  to  a 
minimum.  On  the  left,  the  posterior  ascending  spur  of  the  fissure  of  the  fossa  Sylvii 
and  the  interparietal  fissure  exhibit  their  normal  proportion,  but  the  latter  conceals  in  it 
numerous  plis  de  passage.  The  horizontal  occipital  fissure  exhibits  the  ape-structure. 
The  parieto-temporal  fissure  is  not  well  marked,  but  the  parieto-temporal  operculum  is. 
The  vertical  occipital  fissure  is  connected  with  the  sulcus  hippocampi.  The  first  temporal 
furrow  shows  the  brute  form  by  a  posterior  spur  (the  concavity  directed  downwards). 
The  fissura  Rolandi  is  connected  anteriorly  with  the  first  and  third  frontal  furrows,  and 
in  all  the  fissures  there  are  numerous  opercular  structures.  The  third  frontal  convolu- 
tion is  submerged  at  the  base. 

In  the  case  of  the  first  murderer's  brain  examined,  the  space  of  the  plis  de  passage 
was,  in  the  part  behind  the  posterior  central  convolution,  almost  predominant  over  the 
developed  convolutions,  so  that  a  normal  type  of  convolutions  and  furrows  could  scarcely 
be  drawn.  Here,  also,  the  furrow  of  Rolandi  communicated  with  the  fissura  prsecen- 
tralis.     The  occipital  lobes  scarcely  covered  the  cerebellum. 

For  other  writings  on  thi.s  subject  the  student  is  referred  to  works 
of  Leuret,  Gratiolet,  and  Broca,  in  France ;  Owen  and  Huxley,  and 
their  school,  in  England;  Huschke,  Virchow,  and  Bischofif,  in  Ger- 
many, and  Lombroso,  in  Italy. 


APPENDIX  A. 


AN  ABSTRACT  OF  THE  LAWS 


RELATING  TO   THE 


CARE  AND  CUSTODY  OF  THE  INSANE 


IN  THE  VARIOUS  STATES  OF  THE  UNION. 


WILLIAM  J.  MANN,  Esq., 

MEMBER    OF   THE   NEW   YORK    BAR, 


ARRANGED  ALPHABETICALLY  ACCORDING    TO   SLATES. 


APPENDIX  A. 


ALABAMA. 


[See  Code  of  Alabama  (1876):  sees.  1470-1503,  2753-2769,2782-2784,  2795-2807, 
2894-2895,  3756-3768,  3836,  3843,  3838.] 

The  State  Asylum  is  under  the  management  of  a  board  of  seven  trustees,  appointed  by 
the  governor  with  consent  of  the  Senate,  and  one  of  such  trustees  must  visit  the  asylum 
once  a  week. 

No  person  admitted  to  the  asylum  without  certificate  from  one  or  more  respectable 
physicians  that  he  is  insane. 

The  judge  of  the  probate  court  may  commit  any  indigent  insane  person  to  the  asylum 
after  investigation,  and  calling  one  respectable  physician  and  othe.r  credible  witnesses. 

Guardians  are  appointed  for  the  insane  by  the  judge  of  probate,  who  have  the  care  of 
the  person  and  property  of  their  wards.  They  must  give  bonds  for  the  proper  discharge 
of  their  duties,  and  are  under  the  supervision  and  control  of  the  court. 

When  a  person  has  escaped  indictment,  or  been  acquitted  on  the  ground  of  insanity, 
the  court  must  carefully  inquire  and  ascertain  whether  such  insanity  continues,  and  if 
so,  shall  order  him  to  be  sent  to  the  asylum. 


ARKANSAS. 

[See   Revised   Statutes,    Arkansas   (1874):  sees.    302-326,    1227,    1228,    li 
'-3536,  4496-4500,  4522,  4539.  9.  4539>  1966,  2001,  2002.] 


The  State  Asylum  is  managed  by  five  trustees,  appointed  by  the  governor  with  the 
consent  of  the  Senate. 

Immediately  after  the  appointment  by  the  court  of  any  guardian  for  a  lunatic  or  insane 
person,  such  guardian  shall  take  steps  to  have  the  person  thus  placed  in  his  charge  ad- 
mitted into  said  asylum,  and  on  application  on  behalf  of  a  person  for  admission  into  the 
asylum,  the  superintendent  and  board  of  trustees,  if  they  think  that  such  person  ought 
to  be  admitted,  may  receive  him  as  a  patient  therein,  if  the  person  making  the  applica- 
tion shall  execute  and  deliver  an  obligation,  with  sufficient  security,  payable  to  the  trus- 
tees of  said  asylum,  for  the  payment  of  such  sums  of  money  as  may  be  agreed  on  be- 
tween them  for  the  maintenance  and  care  of  such  lunatic  while  in  the  asylum,  and  for 
his  removakthereto  or  therefrom  when  necessary. — /^ev.  Stat.,  sec.  320. 

Said  superintendent  and  board  of  trustees  shall  also  receive  all  persons  who  may  have 
been  acquitted  of  crimes  and  misdemeanors  on  the  ground  of  insanity,  or  who  may  be 
imprisoned  for  crimes  and  misdemeanors,  upon  the  certificate  of  the  judge  of  the  circuit 
court  before  whom  such  persons  have  been  acquitted  or  are  arraigned  for  trial,  that  such 
persons  are  insane  and  should  be  received  in  such  asylum,  where  they  shall  remain  until 
restored  to  their  right  mind. — Rev.  Stat.,  sec.  321. 

If  friends  of  any  lunatic  neglect  to  place  him  in  asylum  and  permit  him  to  be  at  large, 
it  is  the  duty  of  the  circuit  court  of  the  county,  on  the  suggestion  in  writing  of  any  citizen 
of  the  county,  to  direct  the  sheriff,  by  writ  of  lunacy,  to  summon  twelve  discreet  men  to 
make  inquisition  thereto  on  oath.  If  the  person  said  to  be  a  lunatic  is  adjudged  by  said 
inquest,  or  a  majority  of  them,  to  be  insane,  the  court  shall  order  him  to  be  placed  in  an 
asylum. 


632  APPENDIX    A. 

Guardians  are  appointed  for  the  insane,  who  must  give  suitable  bonds,  and  have  the 
charge  of  the  persons  and  estates  of  their  wards.  The  circuit  courts  have  jurisdiction 
to  appoint  and  superintend  and  control  such  guardians. 


CALIFORNIA. 

[See  Hittell's  Codes  and  Statutes  of  California,  with  supplement  to  18S0,  Title  V., 
chap,  i.,  of  Political  Code,  sees.  2136-2222.  Sections  11,763-11,766,  13,361,  14,367, 
l'4.373.  etc-  Supplement,  sees.  10,372,  10,794,  11,763,  etc..  Statutes  and  Amendments 
to  Code,  18S1,  chap,  ix.,  p.  7;  Statutes  and  Amendments  to  Code,  1883,  chap.  Ixi.,  p. 

2oo,J 

The  State  Asylum  is  under  the  management  of  a  board  of  five  directors,  appointed  by 
the  governor  witli  advice  of  the  Senate. 

Whenever  it  appears,  by  affidavit,  to  the  satisfaction  of  a  magistrate  of  the  county,  that 
any  person  within  the  county  is  so  far  disordered  in  his  mind  as  to  endanger  health,  per- 
son or  property,  he  must  issue  and  deliver  to  some  peace  officer  for  service,  a  warrant, 
directing  that  such  person  be  arrested  and  taken  before  any  judge  of  a  court  of  record 
within  the  county  for  examination. — Political  Code,  sec.  2210. 

The  judge  must  issue  subpoenas  to  two  or  more  witnesses  best  acquainted  with  such 
insane  person,  and  to  two  physicians  to  appear  before  him.  The  physicians  must  hear 
the  testimony  and  make  an  examination  of  the  alleged  insane  person.  If  they  believe 
such  person  to  be  dangerously  insane,  they  must  make  a  ceitificate  showing  as  nearly  as 
possible  : 

1.  That  such  person  is  so  far  disordered  in  his  mind  as  to  endanger  health,  person,  or 
property ; 

2.  The  premonitory  symptoms,  apparent  cause  or  class  of  insanity,  the  duration  and 
condition  of  the  disease  ; 

3.  The  nativity,  age,  residence,  occupation,  and  previous  habits  of  the  person  ; 

4.  The  place  from  whence  the  person  came,  and  the  length  of  his  residence  in  this 
State. 

The  judge,  after  such  examination  and  certificate,  if  he  believes  the  person  insane,  must 
make  an  order  that  he  be  confined  in  the  asylum.  A  copy  of  such  order  shall  be  filed 
with  and  recorded  by  the  county  clerk  of  the  county,  and  the  county  clerk  shall  keep  an 
index  book,  showing  the  name,  age  sex,  of  each  person  so  committed,  together  with  the 
date  of  the  order  and  name  of  asvlum. — Political  Code,  sees.  2210 -22 1 7.  (As  amended 
1881.) 

Guardians  may  be  appointed  to  take  charge  of  the  persons  and  property  of  the  insane, 
subject  to  the  customary  safeguards  and  supervision. 

Every  person  guilty  of  any  harsh,  cruel  or  unkind  treatment  of,  or  of  any  neglect  of  duty 
towards  any  idiot,  lunatic,  or  insane  person,  is  guilty  of  a  misdemeanor. — Penal  Code, 
sec.  13,361. 

COLORADO. 

[See  General  Statute  (1877),  chap.  Ixi.;  Session  Laws,  1879,  pp.  87-92;  Session  Laws, 
1881,  pp.  131  and  141;  Session  Laws,  1883,  p.  32.] 

The  management  of  the  State  Asylum  is  by  a  superintendent  and  a  board  of  three  com- 
missioners appointed  by  the  governor. — Laws,  1879,  p.  87. 

Whenever  any  reputable  person  files  a  verified  complaint  in  the  county  court,  alleging 
that  any  person  is  insane,  and  has  personal  or  real  property,  and  is  incapable  of  taking 
care  of  the  same,  thejudge  shall  thereupon  summon  six  jurors  to  pass  upon  the  case.  If 
said  jury  find  that  such  person  is  so  insane  as  to  be  unfit  to  manage  his  estate,  it  is  the 
duty  of  said  county  court  to  appoint  a  conservator  thereof. 

_  If  complaint  is  made  that  any  person  is  so  insane  or  distracted  in  mind  as  to  endanger 
his  own  person  or  property,  or  the  person  or  property  of  others,  the  judge  shall  issue  an 
order  for  the  apprehension  of  such  alleged  lunatic,  and,  if  he  so  elects,  an  inquest  shall  be 
held  as  set  forth  in  the  preceding  paragraph. 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE.  633 

\  If  the  jury  find  that  the  complaint  is  well  founded,  it  is  the  duty  of  the  court  to 
iomrait  such  lunatic  to  the  county  jail  or  other  convenient  place,  except  that  such  lunatic 
sViall  be  delivered  into  the  custody  of  any  relative  or  friend  who  shall  make  application 
therefor,  and  shall  be  shown  to  be  a  proper  and  suitable  person. 

The  complaints  mentioned  alcove  may  be  joined  and  one  inquest  may  determine  the 
matters  charged  m  both  complaints. 

No  inquest  of  lunacy  shall  be  held  without  ten  days'  notice  to  the  alleged  lunatic  and  to 
the  guardian  ad  litem,  to  be  appointed  by  the  court. 

Laws  of  1879,  p.  90,  Amending  chap.  Ixi.,  of  the  General  Laws  Concerning  Lunatics. 


CONNECTICUT. 

[See  General  Statute  of  Connecticut  (Revision  of  1875),  PP-  96-99-  Laws,  1877,  pp. 
248,  254.     Laws,  1878,  pp.  327,  343.     Laws,  1879,  chap.  71.] 

The  trustees  of  the  State  Flospital  for  the  Insane  may  authorize  the  superintendent  to 
admit  patients  into  the  hospital  under  special  agreements  when  there  are  vacancies. 

Sf.c.  6.  Any  insane  person  may  be  put  in  any  suitable  place  of  detention,  on  the  pres- 
entation of  a  certificate,  made  within  thirty  days,  signed  by  some  reputable  physician, 
that  he  has  made  a  personal  examination  of  such  person  within  one  week  prior  to  the 
date  thereof,  and  that  such  person  is  insane,  which  certificate  shall  be  sworn  to  before 
some  officer  authorized  to  administer  oaths  in  the  State  where  it  is  given,  who  shall  cer- 
tify to  the  genuineness  of  the  signature  thereto,  and  respectability  of  the  signer;  and  any 
such  person  may  be  removed  by  the  person  placing  him  in  such  place  of  detention. — 
General  Statute,  p.  98. 

Sec.  7.  On  a  written  complaint,  made  to  any  judge  of  the  superior  court,  that  a  person 
named  therein  is  insane  and  unfit  to  go  at  large,  such  judge  shall  immediately  appoint  a 
committee,  consisting  of  a  physician  and  two  other  persons,  one  of  whom  shall  be  an  at- 
torney at  law,  judge,  or  justice  of  the  peace,  who,  after  such  person  has  been  notified  ac- 
cording to  the  order  of  such  judge  of  the  superior  court,  shall  inquire  into  such  complaint, 
and  report  to  him  the  facts  of  the  case  and  their  opinions  thereon  ;  and  if,  in  their  opinion, 
such  person  should  be  confined,  such  judge  shall  issue  an  order  therefor. —  General Statitte, 
p.  98. 

Any  dangerous  insane  person  who  shall  go  at  large,  may  be  confined  by  order  of  a 
justice  of  the  peace  and  the  first  selectman  of  the  town,  after  a  physician's  certificate,  or 
after  complaint  to,  and  a  hearing  before,  any  justice  of  the  peace. 

For  proceedings  to  commit  an  insane  pauper  or  indigent  person,  see  Public  Acts,  1878, 

P-327-. 

Any  judge  of  the  superior  court,  on  information  that  any  person  is  unjustly  detained 
or  confined  in  any  insane  asylum,  may  appoint  a  commission  of  not  less  than  two  persons 
to  investigate  the  case  and  report.  If,  in  their  opinion,  the  party  is  improperly  or  illegally 
confined,  the  judge  shall  order  his  discharge. — Public  Acts,  1878,  p.  343. 


DELAWARE. 

[See  Revised  Code,  1852,  as  amended,  etc.,  1874,  chap.,  49 ;  chap.  397,  Vol.  1 1  (eleven). 
Laws  of  Delaware  ;  chap.  57,  Vol.  14,  Laws  of  Delaware,  amended  by  Laws  of  1881 ; 
Laws  of  1875,  Vol.  XV.,  Part  I.,  chap.  57 ;  Laws  of  1881,  Vol.  XVI.,  Part  II.,  chap.  378.] 

The  court  of  chancery  has  care  of  insane  persons  above  the  age  of  twenty-one  years, 
so  far  as  to  appoint  trustees  to  take  charge  of  them  and  manage  their  estates. 

A  writ  must  first  issue  to  inquire  and  determine  by  jury  whether  the  person  is  insane. 

Upon  application  by  relatives  or  friends  of  any  indigent  lunatic  or  insane  person  to  the 
chancellor,  with  certificate  of  two  physicians  practicing  in  the  county  where  such  per- 
son resides,  the  chancellor,  if  satisfied  of  the  insanity  and  indigency  oi^  such  person,  shall 
recommend  in  writing  to  the  governor  his  removal  to  such  asylum,  hospital,  or  institu- 
tion lor  the  insane,  in  Pennsylvania,  as  the  governor  shall  select. 


634  APPENDIX    A. 

The  governor  shall  request  from  such  asylum  an  annual  report,  with  full  details,  as  to 
inmates  sent  from  Delaware,  and  transmit  the  same  to  the  legislature. 

The  court  may,  upon  motion  of  the  attorney-general,  order  any  person  who  has  been 
charged  with  a  crime  punishable  with  death,  and  acquitted  on  the  ground  of  insanity,  to 
be  committed  to  any  lunatic  asylum  in  the  United  States,  and  may  appoint  a  trustee  to 
contract  for  the  support  of  such  person. 


DISTRICT  OF  COLUMBIA. 

[See  United  States  Revised  Statutes,  1S73-74,  Part  II.,  Title  LIX.,  chap,  iv.,  sees, 
4838-4S58.] 

There  sball  be  in  the  District  of  Columbia  a  Government  Hospital  for  the  Insane,  and 
its  objects  shall  be  the  most  humane  care  and  enlightened  curative  treatment  of  the  in- 
sane of  the  army  and  na\y  of  the  United  States,  and  of  the  District  of  Columbia. —  United 
States  Revised  Statutes,  sec.  4838. 

The  superintendent  of  the  Government  Hospital  for  the  Insane  is  appointed  by  the 
Secretar}'  of  the  Interior. 

Nine  citizens  of  the  District  of  Columbia,  appointed  by  the  President,  constitute  a 
Board  of  Visitors  for  the  Hospital  for  the  Insane.  Such  board,  subject  to  the  approval 
of  the  Secretar}'  of  the  Interior,  may  make  any  needful  by-laws  for  the  government  of 
themselves  and  of  the  superintendent  and  his  employes,  and  of  the  patients,  not  incon- 
sistent with  law ;  they  must  also  visit  the  hospital  at  stated  intervals. 

Admission  of  Patients. 

I.  The  superintendent,  upon  the  order  of  the  Secretary  of  War,  of  the  Secretary  of 
the  Xavy,  and  of  the  Secretary  of  the  Treasury,  respectively,  shall  receive  and  keep  in  cus- 
tody, until  they  are  cured  or  removed  by  the  same  authority  which  ordered  their  recep- 
tion, insane  persons  of  the  following  description  : 

First.  Insane  persons  belonging  to  the  army,  navy,  marine  corps,  and  revenue  cutter 
sers'ice. 

Second.  Civilians  employed  in  the  Quartermaster's  and  Subsistence  Department  of  the 
army,  who  maj'  be,  or  who  hereafter  may  become,  insane  while  in  such  employment. 

Third.  Men  who,  while  in  the  service  of  the  United  States,  in  the  army,  navy,  or  marine 
corps,  have  been  admitted  to  the  hospital,  and  have  been  thereafter  discharged  from  it  on 
the  supposition  that  they  have  recovered  their  reason,  and  have  within  three  years  after 
such  discharge  become  again  insane,  from  causes  existing  at  the  time  of  such  discharge, 
and  have  no  adequate  means  of  support. 

Fourth.  Indigent  insane  persons,  who  have  been  in  either  of  the  said  services,  and 
been  discharged  therefrom  on  account  of  disability  arising  from  such  insanity. 

Fifth.  Indigent  insane  persons  who  have  become  insane  within  three  years  after  their 
discharge  from  such  service,  from  causes  which  arose  during,  and  were  produced  by,  said 
service. —  United  States  Revised  Statutes,  sec.  4843. 

II.  The  .-ecretary  of  the  Interior  may  giant  an  order  for  the  admission  into  the  hospital 
of  any  insane  person  not  charged  with  a  breach  of  the  peace,  when  he  shall  receive  the 
certificate  of  any  judge  of  the  Supreme  Court  of  the  District  of  Columbia,  or  of  any  jus- 
tice of  the  peace  of  the  District,  and  an  application  in  writing  by  a  member  of  the  Board 
of  Visitors,  requesting  that  such  order  may  be  issued. 

It  must  appear  by  such  certificate  that  two  respectable  physicians,  residents  of  the  Dis- 
trict, appeared  before  said  judge  or  justice,  and  deposed,  in  writing  sworn  to  and  sub- 
scribed by  them,  that  they  knew  the  person  alleged  to  be  insane,  and  from  personal  ex- 
amination believed  such  person  to  be  in  fact  insane,  and  a  fit  subject  for  treatment  in  said 
hospital ;  also,  that  such  person  was  a  resident  of  the  District  at  the  time  he  or  she  was 
seized  with  such  mental  disorder. 

It  muse  further  appear  by  such  certificate,  that  two  respectable  resident  householders 
appeared  before  the  judge  or  justice,  and  deposed  that  they  knew  the  person  alleged  to  be 
insane,  and.  from  a  personal  examination  of  his  or  her  affairs,  they  believed  said  person 
to  be  unable  to  support  himself  or  family,  and  unable  to  pay  board  and  other  expenses  in 
the  hospital. 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE.  635 

The  application  by  a  member  of  the  Board  of  Visitors  must  be  made  within  five  days 
after  the  date  of  the  affidavits  aforesaid,  and  it  must  appear  therein  to  be  made  after  in- 
spection of  the  affidavits  and  certificate. 

A  patient  able  to  pay  part  of  the  expenses  in  said  hospital  may  be  required  to  do  so 
after  investigation  by  the  Board  of  Visitors. 

Indigent  insane  persons,  non-residents  at  the  time  they  became  insane,  may,  upon  ap- 
plication of  the  governor  of  the  District,  and  certificates  and  application  as  above,  be  ad- 
mitted into  the  hospital  with  a  view  to  their  return  to  their  friends  or  place  of  residence. 
—  United  States  Revised  Statutes,  sees.  4844-4S50. 

III.  Whenever  there  are  vacancies,  private  patients  from  the  District  may  be  received 
at  a  rate  of  board  to  be  determined  by  the  Visitors ;  to  be  in  no  case  less  than  their  actual 
support.  In  this  case  there  must  be  the  certificate  of  two  physicians  stating  that  they  have 
personally  examined  the  patient  and  believe  him  to  be  insane  at  the  time  of  giving  the 
certificate,  and  a  fit  subject  for  treatment  in  the  institution,  accompanied  by  a  written 
request  for  the  admission  from  the  nearest  relative,  legal  guardian,  or  friend  of  the 
patient.  The  request  for  admission  must  be  made  within  five  days  of  the  date  of  the 
certificate  of  insanity.  —  United  States  Revised  Statutes,  sees.  4853-54. 

IV.  Inmates  of  the  National  Home  for  Disabled  Volunteer  Soldiers,  becoming  insane, 
will  be  received  as  patients  in  the  Government  Hospital. — See  United  States  Statutes, 
1881-82,  Vol.  22,  Part  I.,  p.  330. 

V.  As  to  admission  of  insane  criminals,  or  persons  charged  with  crime,  see  United 
States  Revised  Statutes,  sees.  4851,  4852;  United  States  Statutes,  1881-82,  Vol.  22,  Part 
I-,  p.  330. 

FLORIDA. 

[See  McClellan's  Digest  of  the  Laws  of  Florida,  chap.  147,  page  746.] 

Whenever  it  is  suggested,  by  petition  or  otherwise,  to  any  judge  of  the  circuit  court 
of  the  State,  that  there  is  an  insane  person  within  the  limits  of  such  judicial  circuit  in- 
capable of  taking  care  of  himself  or  of  his  property,  it  is  the  duty  of  said  judge  to  issue 
a  writ  to  the  sheriff,  and  cause  such  alleged  lunatic  to  be  brought  before  him.  If  such 
person  is  found,  upon  investigation,  to  be  insane,  the  judge  shall  pass  such  order  or  de- 
cree as  is  usual  or  necessary  in  such  cases.  If  it  appear  that  such  lunatic  has  an  estate, 
the  decree  shall  bind  said  estate.  If  destitute,  then  the  judge  shall  order  the  sheriff  to 
transport  such  lunatic  to  the  asylum  for  indigent  lunatics  of  the  State  of  Florida  :  Pro- 
vided, however-,  tliat  the  judge,  in  his  discretion,  may  direct  said  lunatic  to  be  delivered 
to  any  other  person  for  his  care,  custody,  and  maintenance.  For  such  care,  etc.,  the  said 
person  shall  receive  not  exceeding  ^150  per  annum. 

The  comptroller,,  once  in  every  six  months,  must  send  to  the  State  attorney  of  each  cir- 
cuit a  list  of  the  lunatics  in  the  care  of  private  pei'sons,  and  an  investigation  shall  be  made 
into  each  case  by  the  grand  juries  of  the  several  counties.  By  proceedings  had  before 
the  judge  of  the  circuit  court  the  custody  of  such  lunatics  may  be  changed;  or  they 
may  be  discharged  from  custody,  or  transferred  to  the  State  Asylum. 

The  estates  of  insane  persons  are  managed  generally  by  guardians,  who  may,  upon 
formal  application,  sell  the  real  estate  of  their  wards,  and  may  make  contracts  relating  to 
the  person  and  estate  of  their  wards,  if  approved  by  the  judge  of  the  circuit  court. 


GEORGIA. 

[See  Code  of  the  State  of  Georgia  (1882),  sees.  1852  to  1864  inclusive;  sec.  4666; 
sec.  331 ;  sec.  4299;  sees.  4695,  1658,  2735,  etc  ;  also,  as  to  asylums,  ^ecs.  1341  to  1373 
inclusive.] 

The  ordinaries  of  the  several  counties  may  appoint  guardians  for  the  insane. — Code, 
Sec.  1852. 

Proceedings. — Upon  petition  and  proof  of  ten  days'  notice  to  relatives  of  the  alleged 
lunatic,  the  ordinary  issues  a  commission,  directed  to  any  eighteen  discreet  and  proper 
persons — one  of  whom  shall  be  a  physician — requiring  any  twelve  of  them,  including  the 


6-X,6  APPENDIX    A. 

physician,  to  examine  by  inspection  the  person  for  whom  guardianship  (or  commitment 
to  the  asylum)  is  sought,  and  to  hear  and  examine  witnesses,  if  necessarj".  Upon  return 
of  such  commission  finding  the  person  to  be  as  alleged  in  the  petition,  the  ordinary  shall 
appoint  a  guardian  for  him  (or  commit  him  to  the  lunatic  asylum).  Appeal  lies  from  this 
decision  to  the  Superior  Court. — Code,  sees.  1853  et  seq. ;  64  Ga.,  301  ;  17  Ga.,  595- 
597  '■>  59  Ga.,  675-680;  Cobb's  Anah'sis,  p.  684. 

Guardians  of  insane  persons  are  authorized  to  confine  them  or  place  them  in  the  asy- 
lum, if  such  a  course  is  necessar)-  either  for  their  own  protection  or  the  safety  of  others, 
and  a  guardian  wilfully  failing  to  take  such  a  precaution  with  his  ward  shall  be  responsi- 
ble for  injuries  inflicted  on  others  by  such  ward. — Code,  sec.  1863. 

Where  there  is  no  guardian  for  an  insane  person,  or  the  guardian  fails  to  confine  his 
ward,  and  any  person  shall  make  oath  that  such  insane  person  is  dangerous,  or  should  not 
be  left  at  large,  the  ordinary  .shall  issue  a  warrant,  and,  after  investigation,  may  commit 
such  insane  person  to  the  lunatic  asjdum. — Code,  sec.  1864. 

Courts  of  ordinar}'  have  jurisdiction  over  all  matters  appertaining  to  the  estates  of 
lunatics. — Code,  sec.  331. 

The  State  asylum  is  under  the  management  of  five  trustees,  appointed  by  the  governor, 
one  of  whom  shall  be  a  competent  physician. 

A  pay  patient,  resident  of  this  State,  shall  not  be  admitted  unless  accompanied  by 
authentic  evidence  of  lunacy  according  to  law,  or  there  is  produced  the  certificate  of 
three  respectable  pi-acticing  physicians,  well  acquainted  with  the  condition  of  the  patient, 
or  one  from  such  physicians  and  two  respectable  citizens  stating  the  cause  of  the  appli- 
cation.—  Code,  sec.  1357. 

A  demand  for  trial  by  jury  of  the  question  of  lunacy  may  be  made  before  or  after  ad- 
mission to  the  asylum  by  the  alleged  lunatic  or  his  frends,  and  such  trial  must  be  had. 


ILLINOIS. 

[See  Revised  Statutes  of  Illinois  (Cothran's  Annotated  Edition,  1881),  chap.  85,  page 
950;  Laws  of  Illinois,  i88i,pagei5i ;  Revised  Statutes,  1880  (Hurd),  pages  197,  198,  593, 
580,  694,  734.] 

Each  asylum  for  the  insane  is  managed  by  a  board  of  three  trustees,  appointed  by  the 
governor  with  consent  of  the  Senate. 

When  an}'  person  is  supposed  to  be  insane  or  distracted  any  near  relative,  or  in  case 
there  be  none,  any  respectable  person  residing  in  the  county  may  petition  the  judge  of 
the  county  court  for  proceedings  to  inquire  into  such  alleged  insanity  or  distraction.  For 
the  hearing  of  such  application  and  proceedings  thereon  the  county  court  shall  be  con- 
sidered as  always  open. — Rev.  Stat.  (Cothran's  ed.),  p.  950. 

Such  person  alleged  to  be  insane  shall  be  brought  before  the  court  and  witnesses  shall 
be  subpoenaed. 

Trial  shall  be  had  by  a  jury  of  six  persons,  one  of  whom  shall  be  a  physician,  and  in 
the  presence  of  the  alleged  lunatic,  who  maj'  be  assisted  by  counsel.  If  the  jury  find 
that  such  person  is  insane  the  court  shall  issue  an  order  of  commitment  to  a  State  Hos- 
pital for  the  Insane. 

Pending  trial  the  court  may  order  the  alleged  lunatic  to  be  temporarily  detained  by  the 
sheriff,  jailer,  or  other  suitable  person. 

No  person  shall  be  received  or  kept  in  custody  in  any  asylum  or  hospital  for  the  in- 
sane until  after  the  verdict  of  a  jury  and  by  order  of  the  court.  Any  superintendent  or 
officer  of  an  asylum  recei^-ing  or  detaining  a  person  without  such  verdict  and  order  is 
liable  to  imprisonment  for  one  year  or  to  a  fine  not  exceeding  $500 ;  can  be  held  civilly 
for  damages  by  the  person  injured,  and,  if  connected  with  either  of  the  State  hospitals, 
shall  be  discharged. 

Upon  proper  proceedings  the  courts  will  appoint  conservators  for  the  insane,  to  take 
charge  of  their  person  and  property  and  care  for  their  children  in  certain  cases. 


ABSTRACT    OF    LAWS    RELATING   TO    THE    INSANE.  63/ 


INDIANA. 

[See  Revised  Statutes  of  Indiana,  i88i,secs.  2835-2879,  5142-5150,  2546,  1764,  1765.] 

The  hospital  for  the  insane  is  managed  by  a  board  of  trustees,  two  of  whorh  must  visit 
it  together  monthly. 

Proceedings  for  Commitment. 

A  respectable  citizen  of  the  proper  county  must,  upon  oath  and  in  writing,  make  a 
statement  before  one  of  the  justices  of  the  peace  of  said  county,  such  statement  to  con- 
sist of  full  answers  to  a  long  series  of  questions  provided  by  the  statutes  touching  the 
history,  condition,  heredity,  etc.,  of  the  person  alleged  to  be  insane.  The  justice  with 
whom  said  statement  shall  have  been  filed,  together  with  another  justice  of  the  peace 
and  a  respectable  practicing  physician  other  than  the  medical  attendant  of  the  alleged 
lunatic,  and  selected  by  the  justice,  shall  immediately  thereupon  visit  and  examine  said 
person  alleged  to  be  insane.  Subpoenas  shall  then  be  issued  for  all  witnesses  supposed  to 
be  cognizant  of  the  facts,  including  the  regular  medical  attendant.  Formal  certificates 
provided  for  by  the  statute  must  be  given  by  the  medical  attendant  and  also  the  medical 
examiner.  The  justices  then  make  a  formal  finding  provided  by  the  statute,  and  the  same 
is  deposited  with  the  clerk  of  the  circuit  court  of  the  proper  county.  Such  lunatic  may 
then  be  committed  to  the  asylum,  provided,  that  if  the  proper  friends  of  such  lunatic 
prefer  to  place  him  in  a  private  asylum,  they  shall  be  granted  a  written  authorization  so 
to  do  by  the  clerk  of  the  circuit  court. 

Dangerous  insane  persons  found  at  large  may  be  committed  to  the  asylum  by  any  jus- 
tice of  the  peace  after  proper  complaint  and  trial  by  a  jury  of  six  citizens. 

Guardians  may  be  appointed  for  the  insane  after  proceedings  provided  by  statute,  in- 
cluding trial  by  jury. 

IOWA. 

[See  McClain's  Annotated  Statutes,  1880,  sections  1383-1445,  2272-2279,  etc.;  Re- 
vised Code  of  Iowa  (Miller,  18S0),  sections  1383-1445,  4620-4028.] 

Each  hospital  for  the  insane  is  under  the  charge  of  five  trustees,  two  of  whom  may  be 
women. 

In  each  county  there  shall  be  a  board  of  three  commissioners  of  insanity.  The  clerk 
of  the  circuit  court  shall  be  a  member  of  such  board  and  the  clerk  thereof.  The  other 
members  shall  be  appointed  by  the  judge  of  said  court  and  shall  be  one  of  them  a  prac- 
ticing physician  and  the  other  a  practicing  lawyer. 

Applications  for  admission  to  the  hospital  must  be  made  in  the  form  of  an  information 
verified  by  affidavit,  alleging  that  the  person  in  whose  behalf  the  application  is  made  is 
believed  by  the  informant  to  be  insane  and  a  proper  subject  for  custody  and  treatment. 
Upon  the  filing  of  such  information  the  commissioners  may  examine  the  informant  under 
oath,  and  if  satisfied  there  is  reasonable  cause  therefor,  shall  at  once  investigate  the 
grounds  thereof. 

They  may  issue  their  warrant  and  cause  the  alleged  lunatic  to  be  brought  before  them, 
and  may  provide  for  his  suitable  custody  pending  the  proceedings. 

They  must  take  such  testimony  as  may  be  offered  for  and  against  the  application,  and 
the  parties  may  be  represented  by  counsel.  Personal  examination  of  the  alleged  lunatic 
must  be  made  by  a  physician,  and  such  physician  may  or  may  not  be  one  of  their  own 
number,  and  his  certificate  must  be  taken. 

If  the  commissioners  find  such  person  insane  they  shall  order  his  commitment  to  the 
hospital  for  the  insane. 

An  appeal  lies  to  the  circuit  court  from  the  finding  of  the  commissioners. 

The  commissioners  may  upon  application  and  after  proper  proof  provide  for  the  re- 
straint, protection,  and  care  of  persons  alleged  to  be  insane,  whose  admission  to  the  hos- 
pital is  not  sought. 

Any  person  having  care  of  an  insane  person,  and  restraining  such  person,  whether  in 
the  hospital  or  elsewhere,  either  with  or  without  authority,  wdio  shall  treat  such  person 


638 


APPENDIX   A. 


with  wanton  seveiuty,  harshness,  or  cruelty,  or  shall  in  any  wa}'  abuse  such  person,  shall 
be  guilty  of  a  misdemeanor,  besides  being  liable  in  an  action  for  da.ma.ges.—JlfcC/am's 
Annotated  Stats.,  ?,e:.c.  1415. 

There  shall  be  a  visiting  committee  of  three,  one  of  whom  at  least  shall  be  a  woman, 
appointed  by  the  governor  to  visit  the  insane  asylums  of  the  State  at  their  discretion,  and 
without  giving  notice  of  their  intended  visits,  who  may,  upon  such  visit,  go  through  the 
wards  unaccompanied  by  any  officer  of  the  institution,  with  power  to  send  for  persons  and 
papers,  and  to  examine  witnesses  on  oath  to  ascertain  whether  any  of  the  inmates  are 
improperly  detained  in  the  hospital  or  unjustly  placed  there,  and  whether  the  inmates 
are  humanely  and  kindly  treated,  with  full  power  to  correct  any  abuses  found  to  exist ; 
and  any  injury  inflicted  upon  the  insane  shall  be  treated  as  an  offence,  misdemeanor,  or 
crime,  as  the  like  offence  would  be  regarded  when  inflicted  upon  any  other  citizen  out- 
side of  the  insane  asylum.  They  shall  have  power  to  discharge  any  attendant  or  em- 
ploye who  is  found  to  have  been  guilty  of  misdemeanor  meriting  such  discharge ;  and  in 
all  these  trials  for  misdemeanor,  offence,  or  crime,  the  testimony  of  patients  shall  be  taken 
and  considered  for  what  it  is  worth,  and  no  employe  at  the  asylum  shall  be  allowed  to 
sit  upon  any  jury  before  whom  these  cases  are  tried.  Said  committee  shall  make  an  annual 
report  to  the  governor. 

The  names  of  this  visiting  committee  and  their  post-office  address  shall  be  kept  posted 
in  every  ward  in  the  asylum,  and  every  inmate  in  the  asylum  shall  be  allowed  to  write 
once  a  week  what  he  or  she  pleases  to  this  committee.  And  any  member  of  this  com- 
mittee who  shall  neglect  to  heed  the  calls  of  the  patient  to  him  for  protection,  when  proved 
to  have  been  needed,  shall  be  deemed  unfit  for  his  office,  and  shall  be  discharged  by  the 
governor. 

Every  person  confined  in  any  insane  asylum  shall  be  furnished  by  the  superintendent 
or  party  having  charge  of  such  person,  at  least  once  in  each  week,  with  suitable  materials 
for  writing,  inclosing,  sealing,  and  mailing  letters,  if  they  request  the  same,  unless  other- 
wise ordered  by  the  visiting  committee,  which  order  shall  continue  in  force  until  counter- 
manded by  said  committee. 

The  superintendent  or  party  having  charge  of  any  person  under  confinement  shall  re- 
ceive, if  requested  to  do  so  by  the  person  so  confined,  at  least  one  letter  in  each  week 
addressed  to  one  of  the  visiting  committee,  without  opening  or  reading  the  same,  and 
without  delay  to  deposit  it  in  a  post-office  for  transmittal  by  mail,  with  a  proper  postage 
stamp  affixed  thereto,  and  to  deliver  to  said  person  any  letter  (^without  opening  or  read- 
ing the  same)  written  to  him  or  her  by  one  of  the  visiting  committee.  But  all  other  letters 
written  by  or  to  the  person  so  confined  may  be  examined  by  the  superintendent,  and,  if 
in  his  opinion  the  deliver}^  of  such  letters  would  be  injurious  to  the  person  so  confined, 
he  may  retain  the  same. — McClaui' s  Annotated  Stats.,  sees.  1435-1438. 

A  commission  may  be  appointed  by  a  judge  of  the  district  or  circuit  court  of  the  county 
to  inquire  as  to  the  sanity  of  any  person  confiired  in  the  hospital.  If  upon  the  report  of 
such  commission  the  judge  shall  find  the  person  not  insane  he  shall  order  his  discharge. 

All  persons  confined  as  insane  are  entitled  to  the  benefit  of  the  writ  of  habeas  corpus. 

Guardians  are  appointed  for  the  insane  with  like  provisions  as  in  cases  of  guardians 
for  minors. 


KANSAS. 

[See  Compiled  Laws  of  Kansas  (by  C.  F.  W.  Dassler,  1881),  sees.  435-453,  3060- 
3120,  3416,  4757.] 

The  go^'ernment  of  the  insane  asylums  of  the  State  shall  be  vested  in  the  board  of 
trustees  of  the  institutions  for  the  education  of  the  blind,  the  deaf  and  dumb,  and  the 
asylums  for  the  insane. —  Compiled  Laws  of  Kan.,  sec.  435. 

The  board  of  trustees  shall  designate  the  superintendent  of  one  of  the  insane  asylums, 
to  whom  all  applications  for  the  admission  of  insane  persons  shall  be  made,  and  who, 
under  such  rules  as  may  be  made  by  the  board  of  trustees,  shall  designate  to  which 
asylum  each  applicant  shall  be  admitted. —  Compiled  Laws  of  Kan.,  sec.  436. 

If  information  in  writing  is  given  to  the  probate  court  that  any  one  in  its  county  is  an 
idiot,  lunatic,  or  person  of  unsound  mind,  or  an  habitual  drunkard,  and  incapable  of 
managing  his  affairs,  and  praying  that  an  inquiry  thereinto  be  had,  the  court,  if  satisfied 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE.  639 

that  there  is  good  cause  for  the  exercise  of  its  jurisdiction,  shall  cause  the  facts  to  be 
inquired  into  by  a  jury. —  Compiled  Lazvs  of  Ka7i.,  sec.  3060. 

The  jury  shall  consist  of  six  persons,  one  of  whom  shall,  be  a  practicing  physician. 
The  person  alleged  to  be  insane  has  the  right  to  be  present  and  assisted  by  counsel. 

If  it  appear  that  the  person  is  insane  and  a  fit  person  to  be  sent  to  the  asylum,  the 
court  shall  enter  an  order  of  commitment;  and  if  it  be  found  by  the  jury  that  the  person 
is  of  unsound  mind  and  incapable  of  managing  his  or  her  aifairs,  the  court  shall  appoint 
a  guardian  of  the  person  and  property  of  such  person.  Such  guardian  must  give  suitable 
bonds,  and  is  under  the  full  control  of  the  probate  court. 

In  cases  of  dangerous  insanity,  it  is  the  duty  of  the  giiardian,  or  other  person  in  whose 
care  such  lunatic  may  be,  to  cause  him  to  be  confined  in  some  suitable  place  until  pro- 
ceedings can  be  commenced  in  the  probate  court  of  the  county,  which  shall  make  such 
order  for  the  restraint,  support,  and  safe -keeping  of  such  insane  person  as  circumstances 
require. 

KENTUCKY. 

[See  General  Statutes  of  Kentucky  (B.  &  F.,  1881),  chap.  73,  pp.  642-652;  chap.  53, 
pp.  534-541 ;   Civil  Code  of  Ky.,  sees.  489-498.] 

Each  lunatic  asylum  of  the  State  is  under  the  management  of  a  board  of  nine  com- 
inissioners,  who  shall  be  "discreet  business  men,"  appointed  by  the  governor  with  the 
consent  of  the  Senate. 

They  are  required  to  hold  regular  meetings  at  the  asylum  once  a  month,  and  one  of 
them  shall  visit  the  asylum  once  a  week,  two  in  each  month,  a  majority  in  each  quarter, 
and  the  whole  board  once  in  six  months. 

No  private  patient,  who  has  not  been  found  to  be  insane  by  regular  inquest,  shall  be 
received  into  either  of  said  asylums.  —  Gen.  Stats.,  p.  649. 

In  order  to  relieve  the  State  from  an  undue  accumulation  of  patients,  the  several 
asylums  may  send  to  their  respective  counties  or  places  whence  they  came  patients  who, 
in  the  judgment  of  the  commissioners  and  superintendent,  are  harmless  and  governable. 

The  several  com-ts  of  the  State  having  general  equity  jurisdiction,  have  power  and 
jurisdiction  within  their  respective  counties  over  the  care  and  custody  of  the  persons  and 
estates  of  idiots  and  lunatics. —  Gen.  Stats.,  p.  534. 

If  any  person  be  of  unsound  mind,  it  shall  be  the  duty  of  some  court  of  the  county  in 
which  he  resides,  having  general  equity  jurisdiction,  upon  the  application  of  the  attorney 
of  the  Commonwealth,  or,  if  he  be  absent,  of  the  county  attorney,  to  cause  an  inquest  by 
a  jury  to  be  held  in  open  court  to  inquire  into  the  fact. —  Gen.  Stats.,  p.  537. 

The  court  appoints  counsel  for  the  alleged  lunatic,  and  it  is  the  special  duty  of  the 
attorney  for  the  Commonwealth,  or  for  the  county,  to  prevent  the  finding  of  any  person 
as  an  idiot  or  lunatic  who,  in  his  opinion,  is  not  such. 

If  upon  such  inquest  any  person  is  found  to  be  of  unsound  mind,  and  incompetent  to 
manage  his  or  her  estate,  the  court  will  appoint  a  committee  for  such  lunatic  ancl  may  or- 
der his  commitment  to  an  asylum. 

The  power  and  duty  of  the  committee  of  a  lunatic  or  imbecile  is  the  same  as  that  of 
the  guardian  of  an  infant,  except  as  to  education.  But  the  court  may  appoint  a  person 
other  than  the  committee  to  take  charge  of  the  person  of  the  idiot  or  lunatic  when  not 
confined  in  an  asylum,  and  make  the  necessary  orders  for  his  support  upon  the  committee. 

The  officer  who  presides  at  the  inquest  shall  endeavor  to  ascertain  and  draw  up  a  brief 
history  of  the  patient's  case,  embracing  points  provided  by  the  statute,  and  such  statement, 
or  a  copy,  shall  be  sent  with  the  record  to  the  asylum,  if  the  lunatic  is  sent. 

No  person  not  otherwise  insane  shall  be  sent  to  an  asylum  merely  because  he  is  subject 
to  epileptic  fits,  or  thereby  rendered  helpless. —  Gen.  Stats.,  p.  541. 


LOUISIANA. 

[See  Voorhies's  Revised  Statutes  of  Louisiana,  1876,  sees.  1760-1780.] 

The  State  asylum  is  under  the  management  of  a  board  of  five  administrators,  appointed 
by  the  governor  with  the  advice  and  consent  of  the  Senate. 

At  every  regular  meeting  the  board  shall  appoint  two  of  its  members,  who  shall  visit 


640 


APPENDIX    A. 


said  asylum  at  least  once  a  week.  The  board  shall  furnish  a  report  to  the  legislature  at 
each  session. 

Upon  petition  and  oath  of  any  individual,  and  after  "  proper  inquiry  into  all  the  facts 
and  circumstances  of  the  case,"  the  district  or  parish  judge  may  cause  any  lunatic  to  be 
committed  to  the  insane  asylum. 

The  board  of  administrators  have  authority  to  receive  insane  persons,  not  sent  to  the 
asylum  by  a  district  or  parish  judge,  on  such  terms  and  conditions  as  they  may  deem  fit 
to  adopt. 

Prisoners  acquitted  on  the  ground  of  insanity  may  be  sent  to  the  asylum  until  restored. 

A  curator  or  guardian  may  be  appointed  for  an  insane  person,  who  shall  have  the  care 
of  the  person  and  property  of  such  interdicted  person  or  ward. —  Voorhies''s  Revised 
Statutes,  sees.  1095  to  11 13  inclusive;  and  Revised  Civil  Code  of  Louisiaria,  Title  IX., 
P-  50- 

MAINE. 

[See  Revised  Statutes  of  Maine  (1871),  chap.  143,  pp.  927-933;  also  pp.  58,  533,  534, 
540,  537,  643,  694,  632,  770,  651,  652,  749,  898,  899,  923;  Laws  of  1872,  chap.  54; 
Laws  of  1873,  chap.  151 ;  Laws  of  1874,  chap.  256;  Laws  of  1876,  chap.  I17;  Laws  of 
1877,  chap.  188;   Laws  of  1879,  chap.  160;   Laws  of  1880,  chap.  184.] 

The  government  of  the  Maine  Insane  Hospital  is  vested  in  a  committee  of  six  trustees, 
one  of  whom  shall  be  a  woman,  appointed  by  the  governor,  with  the  advice  of  the  council, 
and  commissioned  to  hold  their  office  during  the  pleasure  of  the  governor  and  council, 
but  not  more  than  three  years  under  any  one  appointment. — Lazvs  0/ 1S80,  chap.  184. 

In  all  cases  of  preliminaiy  proceedings  for  the  commitment  of  any  person  to  the  hos- 
pital, the  e\'idence  and  certificate  of  at  least  two  respectable  physicians,  based  upon  due 
inquiry'  and  personal  examination  of  the  person  to  whom  the  insanity  is  imputed,  shall 
be  required  to  establish  the  fact  of  insanity,  and  a  certified  copy  of  the  physician's  certifi- 
cate shall  accompany  the  person  to  be  committed. — Laws  of  1876,  chap.  117. 

A  committee  of  the  council,  consisting  of  two,  with  whom  shall  be  associated  one 
woman,  shall  be  appointed  by  the  governor  annually,  who  shall  visit  the  hospital  at  their 
discretion  to  ascertain  if  the  inmates  thereof  are  humanely  treated,  and  they  shall  make 
prompt  report  from  time  to  time  of  every  instance  of  intentional  abuse  or  ill-treatment  to 
the  trustees  and  superintendent  of  the  hospital,  who  shall  take  notice  thereof,  and  cause 
the  offender  to  be  punished  as  required  by  section  twenty-eight,  chapter  one  hundred  and 
forty-three  of  the  Revised  Statutes. — Laws  of  1S74,  chap.  256,  sec.  4. 

If  any  wilful  injuiy  shall  be  inflicted  by  any  officer,  attendant,  or  employe  of  the  hos- 
pital, upon  the  person  of  any  patient  therein,  and  knowledge  thereof  shall  come  to  the 
said  committee  of  visitors,  they  shall  report  the  fact  immediately  to  the  said  trustees  and 
superintendent ;  and  if  the  superintendent  fails  forthwith  to  complain  thereof,  as  required 
by  the  statute  aforesaid,  one  of  the  said  visitors  shall  enter  a  complaint  thereof  before  the 
court  having  jurisdiction  of  such  offence,  and,  on  conviction,  the  offender  shall  be  pun- 
ished as  provided  by  lav.-.  And  in  all  trials  for  such  offences,  the  statement  of  any  patient 
cognizant  thereof  shall  be  taken  and  considered  for  what  it  may  be  worth,  and  no  one 
connected  with  the  hospital  shall  be  allowed  to  sit  upon  the  jury  which  shall  try  the  case. 
— Laws  of  1874,  chap,  256,  sec.  5. 

In  case  of  the  sudden  death  of  any  patient  in  the  hospital,  under  circumstances  of 
reasonable  suspicion  as  to  the  innocent  cause  thereof,  a  coroners  inquest  shall  be  held, 
as  provided  by  law  in  other  cases,  and  the  committee  of  visitors  shall  cause  a  coroner  to 
be  immediately  notified  for  that  purpose. — Laws  of  1874,  chap.  256,  sec.  6. 

If  the  committee  are  satisfied  that  any  inmate  has  been  improperly  committed,  or  is 
unnecessarily  detained,  they  shall  make  application  to  the  proper  judge  for  a  writ  of 
habeas  corpus,  who,  after  a  full  hearing,  shall  order  the  discharge  of  such  inmate,  if  con- 
vinced that  he  is  not  a  proper  subject  for  custody. — Laws  of  1874,  chap.  256,  sec.  8. 

The  names  of  the  committee  of  visitors  shall  be  posted  in  the  wards,  and  easily  acces- 
sible locked  letter-boxes  provided,  and  the  inmates  shall  be  provided  with  writing  mate- 
rials and  allowed  to  write  what  and  when  they  may  please  to  any  member  of  such  visiting 
committee.  No  officer  or  attendant  of  the  hospital  shall  be  allowed  the  means  of  reaching 
the  contents  of  such  boxes. 

Letters  shall  be  delivered  to  patients  without  being  opened,  if  forwarded  by  the  com- 


ABSTRACT    OF   LAWS    RELATING   TO    THE    INSANE.  64 1 

mittee,  or  directed  to  such  inmate  as  the  committee  have  authorized  to  receive  or  send 
letters  without  their  inspection. — Laws  of  1874,  chap.  256,  sees.  9-10. 

Hospital  to  be  visited  at  least  once  a  month,  at  irregular  intervals  and  without  notice, 
but  as  far  as  possible  unexpectedly,  by  a  member  of  committee,  who  shall  not  be' 
accompanied  by  any  officer  or  employe  of  the  hospital  when  making  his  visits,  except 
upon  his  special  request. 

The  committee  of  visitors  shall  report  annually,  and  as  much  oftener  as  necessary,  to 
the  governor  and  council. — Laws  of  1874,  chap.  256,  sees.  11-12. 

The  judge  of  probate  may  appoint  a  guardian  for  any  insane  person,  and  such  guardian 
has  the  care  of  the  person  and  estate  of  his  ward,  subject  to  the  control  of  the  court. — 
Rev.  Stats.,  chap.  67. 

As  to  commitment  to  asylum  of  person  indicted  and  acquitted  on  ground  of  insanity, 
or  against  whom  the  grand  jury  omits  to  find  for  same  cause,  see  Laws  of  1879,  chap. 
160. 

Proceedings  for  transferring  insane  inmates  of  State  prison  or  county  jail  to  asylum, 
see  Laws  of  1877,  chap.  189. 

MARYLAND. 

[As  to  the  Maryland  Hospital  for  the  Insane,  see  Revised  Code  of  Maryland,  1878,  Ar- 
ticle 26,  p.  242;  Laws  of  Maryland,  1880,  chap.  314.  Generally  as  to  care  and  mainte- 
nance of  the  insane,  see  Revised  Code  of  Maryland,  1878,  Article  53,  and  Maryland  Code 
Public  General  Laws,  i860.  Article,  16,  sees.  79-87.  As  to  insane  or  lunatic  convicts. 
Revised  Code  (1878),  Article  6,  p.  62.] 

A  court  of  equity  may,  on  the  application  of  any  trustee  of  a  person  no7i  compos  f?ientis, 
and  receiving  proof  that  it  is  necessary  and  proper  to  confine  such  person,  direct  such 
trustee  to  send  the  person  under  his  charge  to  any  hospital  in  the  vicinity  of  the  city  of 
Baltimore,  provided  he  can  be  there  received,  to  remain  until  the  further  order  of  the 
court. — Rev.  Code,  Art.  53,  sec.  i. 

When  any  person  is  alleged  to  be  a  lunatic  or  insane  pauper,  trial  by  a  jury  shall  be 
had  before  such  person  is  committed  to  an  asylum.— TPfz/.  Code,  Art.  53. 

Prisoner  acquitted  on  ground  of  insanity  shall  be  confined  in  some  suitable  place  until 
he  shall  have  recovered  his  reason,  and  be  discharged  by  due  course  of  law. — Rev.  Code, 
Art.  53.  ■ 

The  courts  have  full  power  to  superintend  and  direct  the  care  of  the  insane,  both  as 
to  their  person  and  the  management  of  their  property,  and  appoint  a  committee  or  a 
trustee  or  trustees  for  such  persons. 


MASSACHUSETTS. 

Following  are  public  statutes  of  the  Commonwealth  of  Massachusetts,  enacted  Novem- 
ber 19,  1 88 1,  to  take  effect  February  i,  1882. 

General  Duties  of  State  Board. 

Chapter  87,  Section  i.  The  State  board  of  health,  lunacy  and  charity  shall  act  as 
commissioners  of  lunacy,  with  power  to  investigate  the  question  of  the  insanity  and  con- 
dition of  any  person  committed  to  any  lunatic  hospital  or  asylum,  public  or  private,  or 
restrained  of  his  liberty  by  reason  of  alleged  insanity,  at  any  place  within  this  Common- 
wealth;  and  shall  discharge  any  person  so  committed  or  restrained,  if  in  its  opinion  such 
person  is  not  insane,  or  can  be  cared  for  after  such  discharge  without  danger  to  others 
and  with  benefit  to  himself. 

State  Lunatic  Hospitals. 
Sec.  4.  The  government  of  each  of  the  State  lunatic  hospitals,  at  Worcester,  Taunton, 
Northampton,  and  Danvers,  shall  be  vested  in  a  board  of  five  trustees,  appointed  and 
commissioned  by  the  governor  with  the  advice  and  consent  of  tire  council,  subject  to  re- 
moval only  for  sufficient  cause. 

41 


642 


APPENDIX    A. 


Commitments  to  Hospitals. 


Sec.  II.  a  judge  of  the  supreme  judicial  court  or  superior  court,  in  any  county 
where  he  may  be,  and  a  judge  of  the  probate  court,  or  of  a  police  district  or  municipal 
court  within  his  county,  may  commit  to  either  of  the  State  lunatic  hospitals,  any  in- 
sane person,  then  residing  or  being  in  said  county,  who,  in  his  opinion,  is  a  proper  sub- 
ject for  its  treatment  or  custody. 

Sec.  12.  Except  when  otherwise  specially  provided,  no  person  shall  be  committed  to 
a  lunatic  hospital,  asylum,  or  other  receptacle  for  the  insane,  public  or  private,  with- 
out an  order  or  certificate  therefor,  signed  by  one  of  the  judges  named  in  the  preced- 
ing section,  said  person  residing  or  being  within  the  county  as  therein  provided.  Such 
order  or  certificate  shall  state  that  the  judge  finds  that  the  person  committed  is  insane, 
and  is  a  fit  person  for  treatment  in  an  insane  asylum.  And  said  judge  shall  see  and  ex- 
amine the  person  alleged  to  be  insane,  or  state  in  his  final  order  the  reason  why  it  was 
not  deemed  necessary  or  advisable  to  do  so.  The  hearing,  except  when  a  jury  is  sum- 
moned, shall  be  at  such  place  as  the  judge  shall  appoint.  In  all  cases  the  judge  shall 
certify  in  what  place  the  lunatic  resided  at  the  time  of  his  commitment ;  or  If  the  con- 
finement is  ordered  by  a  court,  the  judge  shall  certifiy  in  what  place  the  lunatic  resided 
at  the  time  of  the  arrest  in  pursuance  of  which  he  was  held  to  answer  before  such  court ; 
and  such  certificate  shall,  for  the  purposes  of  the  preceding  section,  be  conclusive  evi- 
dence of  his  residence. 

Sec.  13.  No  person  shall  be  so  committed,  unless  in  addition  to  the  oral  testimony  there 
has  been  filed  with  the  judge  a  certificate  signed  by  two  physicians,  each  of  whom  is  a 
graduate  of  some  legally  organized  medical  college,  and  has  practiced  three  years  in  the 
State,  and  neither  of  whom  is  connected  with  any  hospital  or  other  establishment  for 
treatment  of  the  insane.  Each  must  have  personally  examined  the  person  alleged  to 
be  insane,  within  five  days  of  signing  the  certificate,  and  each  shall  certify  that  in  his 
opinion  said  person  is  insane  and  a  proper  subject  for  treatment  in  an  insane  hospital, 
and  shall  specify  the  facts  on  which  his  opinion  is  founded.  A  copy  of  the  certificate, 
attested  Jjy  the  judge,  shall  be  delivered  b)-  the  officer  or  other  person  making  the  com- 
mitment to  the  superintendent  of  the  hospital  or  other  place  of  commitment,  and  shall  be 
filed  and  kept  with  the  order. 

Sec.  14.  A  person  applying  for  the  commitment  or  for  the  admission  of  a  lunatic  to 
a  State  lunatic  hospital,  under  the  provisions  of  this  chapter,  shall  first  give  notice  in 
writing  to  the  mayor  or  one  or  more  of  the  selectmen  of  the  place  where  the  lunatic  re- 
sides, of  his  intention  to  make  such  application,  and  satisfactory  evidence  that  such 
notice  has  been  given  shall  be  produced  to  the  judge  in  cases  of  commitment. 

Sec.  15.  Upon  ever}'  application  for  the  commitment  or  admission  of  an  insane  person 
to  a  hospital  or  asylum  for  the  insane,  there  shall  be  filed  with  the  application,  or  within 
ten  days  after  the  commitment  or  admission,  a  statement  in  respect  to  such  person,  show- 
ing, as  nearly  as  can  be  ascertained,  his  age,  birthplace,  civil  condition  and  occupation, 
the  supposed  cause,  and  the  duration  and  character  of  his  disease,  whether  mild,  violent, 
dangerous,  homicidal,  suicidal,  paralytic  or  epileptic,  the  previous  or  present  existence 
of  insanity  in  the  person  or  his  family  ;  his  habits  in  regard  to  temperance,  whether  he 
has  been  in  any  lunatic  hospital,  and,  if  so,  what  one,  when,  and  how  long,  and  if  the 
patient  is  a  woman,  whether  she  has  borne  children,  and,  if  so,  what  time  has  elapsed 
since  the  birth  of  the  youngest;  the  names  and  address  of  his  father,  mother,  children, 
brothers,  sisters  or  other  next  of  kin,  not  exceeding  ten  in  number,  and  over  eighteen 
years  of  age,  when  the  names  and  address  of  such  relatives  are  known  by  the  person  or 
persons  making  such  application,  together  with  any  facts  showing  whether  he  has  or  has 
not  a  settlement,  and  if  he  has  a  settlement,  in  what  place  ;  and  if  the  applicant  is  un- 
able to  state  any  of  the  above  particulars,  he  shall  state  his  inability  to  do  so.  The  state- 
ment, or  a  copy  thereof,  shall  be  transmitted  to  the  superintendent  of  the  hospital  or  asylum, 
to  be  filed  with  the  order  of  commitment  or  the  application  for  admission.  The  super- 
intendent shall,  within  two  days  from  the  time  of  the  admission  or  commitment  of  an 
insane  person,  send,  or  cause  to  be  sent,  notice  of  said  commitment  in  writing,  by  mail, 
postage  prepaid,  to  each  of  said  relatives,  and  to  any  other  two  persons  whom  the  person 
committed  shall  designate. 

Sec.  16.  After  hearing  such  other  evidence  as  he  may  deem  proper,  the  judge  may 
issue  a  warrant  for  the  apprehension  and  bringing  before  him  of  the  alleged  lunatic,  if  in 
his  judgment  the  condition  or  conduct  of  such  person  renders  it  necessary  or  proper  to 
do  so.  Such  warrant  may  be  directed  to  and  be  served  by  a  private  person  named  in 
said  warrant,  as  well   as   by  a  qualified   officer ;   and   pending  examination   and  hearing, 


ABSTRACT   OF    LAWS    RELATING    TO    THE    INSANE.  643 

such  order  may  be  made  concerning  the  care,  custody  or  confinement  of  such  alletred  lu- 
natic as  the  judge  shall  see  fit.  '^ 

_  Sec.  17.  The  judge  may,  in  his  discretion,  issue  a  warrant  to  the  sheriff  or  his  deputy 
directmg  him  to  summon  a  jury  of  six  lawful  men,  to  hear  and  determine  whether  the 
alleged  lunatic  is  insane. 

Sec.  19.  The  judge  shall  preside  at  such  trial  and  administer  to  the  jury  an  oath 
faithfully  and  impartially  to  try  the  issue,  and  the  verdict  of  the  jury  shall  be  final  on 
the  complaint. 

Sec.  25.  When  the  State  board  has  reason  to  believe  that  any  insane  person,  not  in- 
curable, is  deprived  of  proper  remedial  treatment,  and  is  confined  m  an  almshouse  or  other 
place,  whether  such  insane  person  is  a  public  charge  or  otherwise,  it  shall  cause  appli- 
cation to  be  made  to  a  judge  for  the  commitment  of  such  person  to  a  hospital  in  the 
manner  herein  prescribed. 

Sec.  26.  The  superintendent  or  keeper  of  any  lunatic  hospital,  including  the  McLean 
Asylum  at  Somerville,  may  receive  into  his  custody  and  detain  in  such  hospital  or  asy- 
lum for  a  period  not  exceeding  five  days  without  an  order  of  a  judge  as  provided  in  sec- 
tion eleven,  any  person  as  insane,  whose  case  is  duly  certified  to  be  one  of  violent  and 
dangerous  insanity  and  emergency  by  two  physicians,  qualified  as  provided  in  section 
thirteen,  which  certificates  shall  be  separately  made  and  signed,  and  shall  conform  in  all 
other  respects  to  the  provisions  of  section  thirteen.  In  addition  to  such  certificates,  an  appli- 
cation signed  by  one  of  the  selectment  of  the  town,  or  by  the  mayor  or  one  of  the  aldermen 
of  the  city  in  which  such  insaue  person  resides  or  is  found,  shall  be  left  with  the  superin- 
tendent of  the  hospital  or  asylum  in  which  the  insane  person  is  received,  and  such  ap- 
plication shall  contain  the  statement  in  respect  to  such  insane  person  which  is  required 
by  section  fifteen,  and  a  further  statement  that  the  case  is  one  of  violent  and  dangerous 
insanity. 

Sec.  27.  When  an  insane  person  is  committed  to  a  lunatic  hospital  or  asylum  in  ac- 
cordance with  the  provisions  of  the  preceding  section,  the  party  committing  such  person 
shall  give  a  bond  in  the  sum  of  one  hundred  dollars  to  the  treasurer  of  such  hospital 
or  asylum,  with  condition  that  he  will,  within  five  days,  procure  an  order  for  the  com- 
mitment of  said  patient  as  provided  in  section  eleven,  or  failing  thereof  will  remove 
him. 

Sec.  28.  The  superintendent  or  keeper  of  any  hospital  as  aforesaid,  may  receive  and 
detain  therein,  as  a  boarder  and  patient,  any  person  who  is  desirous  of  submitthig  himself 
to  treatment,  and  makes  written  application  therefor,  but  whose  mental  condition  is  not 
such  as  to  render  it  legal  to  grant  a  certificate  of  insanity  in  his  case.  No  such  boarder 
shall  be  detained  for  more  than  three  days  after  having  given  notice  in  writing  of  his 
intention  or  desire  to  leave  such  hospital. 

Sec.  29.  When  a  patient  is  received  into  any  such  hospital  upon  his  own  application 
or  under  the  provisions  of  section  twenty-six,  the  superintendent  thereof  shall  give  imme- 
diate notice  of  such  reception  to  the  State  board  of  health,  lunacy  and  charity,  stating  all 
the  particulars  of  the  case,  including  the  legal  settlement  of  the  person  so  received,  if 
known;  and  said  board  shall  immediately  cause  such  cases  to  be  investigated  and  a 
record  to  be  made  of  all  the  facts  pertaining  thereto. 

Sec.  30.  Any  physician  who  wilfully  conspires  with  any  person,  unlawfully  or  im- 
properly, to  commit  to  any  lunatic  hospital  or  asylum  in  this  State,  any  person  who  is 
not  insane,  shall  be  punished  by  fine  or  imprisonment  at  the  discretion  of  the  court. 

Certain  Privileges  of  Patients  in  Hospitals, 

Sec.  35.  An  attorney-at-law  regularly  retained  by  or  on  behalf  of  any  person  com- 
mitted to  a  lunatic  hospital,  asylum  or  receptacle  for  the  insane,  shall  be  admitted  to  visit 
such  client  at  all  reasonable  times,  if,  in  the  opinion  of  the  superintending  officer  of  such 
hospital,  asylum  or  receptacle,  such  visit  would  not  be  injurious  to  such  person,  or  if  a 
judge  of  the  supreme  judicial  court,  superior  court  or  probate  court  in  any  county  first 
orders  in  writing  that  such  visits  be  allowed. 

Sec.  36.  All  patients  in  any  lunatic  hospital,  asylum  or  receptacle  for  the  insane  shall 
be  allowed  to  write  monthly  to  the  superintendent  and  to  the  State  board ;  and  they 
shall  be  furnished  by  the  superintendent  with  all  materials  necessary  for  such  corre- 
spondence. A  locked  box  shall  be  placed  in  each  ward,  in  which  each  writer  may  de- 
posit his  letters,  and  the  boxes  shall  be  opened  and  the  letters  distributed  monthly  by  the 
State  bo^rd. 


644  APPENDIX    A. 

Transfer  and  Discharge  of  Lunatics. 

Sec.  40.  Any  two  of  the  trustees  of  a  State  Lunatic  Asylum,  on  an  application  in 
writing  or  of  their  own  motion,  or  any  judge  of  the  supreme  judicial  court,  at  any  time  and 
in  any  count}",  or  the  judge  of  the  probate  court  for  the  county  in  which  the  hospital  is 
situated,  or  in  which  the  patient  had  his  residence  at  the  time  of  his  commitment  or  ad- 
mission, on  such  application,  and  after  such  notice  as  the  said  trustees  or  judge  may  deem 
reasonable  and  proper,  may  discharge  any  person  confined  therein,  if  it  appears  that  such 
person  is  not  insane,  or,  if  insane  will  be  sufficiently  provided  for  by  himself,  his  guardian, 
relatives  or  friends,  or  by  the  citj-  or  town  liable  for  his  support,  or  that  his  confinement 
therein  is  not  longer  necessar}'  for  the  safety  of  the  public  or  his  own  welfare. 

Sec.  41.  Any  two  of  the  trustees  may  also  remove  any  person  confined  therein,  to  the 
city  or  town  in  which  the  judge  committing  him  certified  that  he  resided  at  the  time  of 
the  order  for  commitment,  or  to  the  place  of  his  settlement,  when,  in  their  opinion,  he 
ceases  to  be  dangerous,  and  is  not  susceptible  of  mental  improvement  at  the  hospital,  if 
such  city  or  town  does  not  remove  him  after  reasonable  notice  in  writing. 

Sec.  42.  Any  person  may  make  written  application  to  a  judge  of  the  supreme  judicial 
court  at  any  time  and  in  any  county,  setting  forth  that  he  believes  or  has  reason  to  be- 
lieve that  a  person  therein  named  is  confined  as  an  insane  person  in  a  lunatic  hospital  or 
other  place,  whether  public  or  private,  and  ought  not  longer  to  be  so  confined,  and  stat- 
ing the  names  of  all  persons  supposed  to  be  interested  in  keeping  him  in  confinement, 
and  requesting  his  discharge. 

Sec.  43.  The  judge,  upon  reasonable  cause  being  shown  for  a  hearing,  shall  order 
notice  of  the  time  and  place  of  hearing  on  said  application,  to  be  given  to  the  superintend- 
ent in  charge  of  the  hospital  or  place  of  confinement,  and  to  such  other  persons  as  he 
deems  proper,  and  such  hearing  when  ordered  shall  be  had  as  speedily  as  conveniently 
may  be,  before  any  judge  of  the  supreme  judicial  court  in  any  county.  The  alleged  in- 
sane person  may  be  brought  before  the  judge  at  the  hearing  upon  a  writ  of  habeas  corpus, 
if  anj"  person  so  requests  and  the  judge  deems  it  proper,  and  an  issue  or  issues  maj-  be 
framed  and  submitted  to  a  jurv'  hv  direction  of  the  judge  or  on  the  request  of  any  person 
who  appears  in  the  case.  The  jurors  may  be  those  in  attendance  on  said  court,  if  in 
session  at  the  time  of  the  hearing,  or  may  be  summoned  for  the  special  purpose  on 
venires  issued  by  the  clerk  of  said  court  upon  the  order  of  the  judge,  substantially  in 
accordance  with  the  provisions  of  chapter  1 70. 

Sec.  44.  If  it  appears  upon  the  verdict  of  the  jur}-,  or  in  the  opinion  of  the  judge,  if 
not  submitted  to  a  jur\%  that  the  person  so  confined  is  not  insane,  or  that  he  is  not  dan- 
gerous to  himself  or  others,  and  ought  not  longer  to  be  so  confined,  he  shall  be  discharged 
from  such  confinement. 

County  Receptacles. 

Sec.  46.  There  shall  be  in  each  county  within  the  precincts  of  the  house  of  correction, 
or  if  in  the  judgment  of  the  county  commissioners  it  cannot  be  conveniently  provided 
within  the  same,  then  in  some  other  building  or  buildings,  to  be  deemed  a  part  of  the 
house  of  correction,  a  convenient  apartment  or  receptacle  for  the  confinement  of  insane 
persons  not  furiouslj"  mad. 

Sec.  4S.  Any  judge  authorized  under  this  chapter  to  commit  lunatics  may,  in  his  dis- 
cretion, commit  an  insane  person  not  furiously  mad,  and  having  a  settlement  in  this 
State,  to  the  county  receptacle  aforesaid. 

Sec.  49.  Provision  shall  be  made  for  the  comfortable  support  of  all  persons  confined 
in  said  receptacles,  and  they  shall  be  governed  or  employed  in  such  marmer  as  the 
county  commissioners  may,  in  the  exercise  of  their  discretion,  deem  best.  Such  sum  a 
week  shall  be  allowed  and  paid  for  the  support  of  the  persons  so  confined  as  the  com- 
missioners shall  direct,  and  the  same  may  be  recovered  of  such  person,  or  of  any  parent, 
kindred,  master,  guardian,  cit}'  or  town  bound  by  law  to  maintain  him. 

Sec.  50.  Any  insane  person  confined  by  legal  authority  in  a  jail,  house  of  correction, 
or  such  count)-  receptacle,  may  be  removed  therefrom  to  either  of  the  State  lunatic  hos- 
pitals, or  to  any  other  jail,  house  of  correction,  or  other  suitable  place,  by  order  of  the 
governor,  when  it  appears  to  him  that  such  removal  would  be  expedient  and  just ;  and  the 
sheriff  of  the  county  in  which  such  person  is  confined  shall  execute  such  order  and  convey 
the  insane  person  to  the  place  therein  designated. 

Sec.  51.  Any  person  confined  by  virtue  of  section  48  may  be  discharged,  when,  in  the 
opinion  of  a  judge  authorized  to  commit  insane  persons,  such  discharge  would  be  for  the 
benefit  of  such  person,  or  when  in  his  opinion  such  person  would  be  comfortably  sup- 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE,  645 

ported  by  any  parent,  kindred,  friend,  master  or  guardian,  or  by  any  place  in  which  he 
has  a  legal  settlement. 

Private  Insane  Asylums. 

Sec.  53.  The  governor  and  council  may  license  any  suitable  person  to  establish  and 
keep  an  asylum  or  private  house  for  the  reception  and  treatment  of  insage  persons,  and  may 
at  any  time  revoke  such  license.  And  such  asylum  or  private  house  shall  be  subject  to  vis- 
itation by  the  governor  and  council  or  any  committee  thereof,  and  by  the  judge  of  the 
probate  court  of  the  county  wherein  the  same  is  situated. 

Sec.  54.  Whoever  establishes  or  keeps  such  an  asylum  or  private  house  without  a  li- 
cense, unless  otherwise  authorized  by  law,  shall  forfeit  a  sum  not  exceeding  five  hundred 
dollars. 

Chap.  213,  Sec.  15.  When  a  person  held  in  prison  on  a  charge  of  having  committed 
an  indictable  offence,  is  not  indicted  by  the  grand  jury  by  reason  of  insanity,  the  grand 
jury  shall  certify  that  fact  to  the  court,  and  thereupon  the  court,  if  satisfied  that  he  is  in- 
sane, may  order  him  to  be  committed  to  a  State  lunatic  hospital,  under  such  limitation  as 
may  seem  proper. 

Sec.  30.  A  judge  of  the  supreme  judicial  court  sitting  for  the  arraignment  of  a  person 
charged  with  murder  shall  have  the  same  power  to  commit  such  person  to  a  lunatic 
hospital,  if  found  by  him  to  be  insane,  as  the  court  would  have  if  sitting  at  a  regular  term 
thereof. 

Chap.  214,  Sec.  16.  When  a  person  indicted  is,  at  the  time  appointed  for  the  trial, 
found,  to  the  satisfaction  of  the  court,  to  be  insane,  the  court  may  cause  him  to  be  re- 
moved to  one  of  the  State  lunatic  hospitals  for  such  a  term  and  under  such  limitations  as 
it  may  direct. 

Sec.  19.  When  a  person  is  acquitted  by  the  jury  by  reason  of  insanity,  the  jury  shall 
state  that  fact  to  the  court,  and  thereupon  the  court,  if  satisfied  that  he  is  insane,  may 
order  him  to  be  committed  to  a  State  lunatic  hospital,  under  such  limitations  as  may 
seem  proper. 

Sec.  20.  When  a  person  indicted  for  murder  or  manslaughter  is  acquitted  by  the  jury 
by  reason  of  insanity,  the  court  shall  order  such  person  to  be  committed  to  one  of  the 
State  lunatic  hospitals  during  his  natural  life. 

Sec.  21.  Any  person  committed  to  a  State  lunatic  hospital,  under  the  preceding 
section,  may  be  discharged  therefrom  by  the  governor,  by  and  with  the  advice  and  con- 
sent of  the  council,  when  he  is  satisfied,  after  a  hearing  of  the  matter,  that  such  person 
may  be  discharged  without  danger  to  others. 

Chap.  215,  Sec.  34.  If  a  person  convicted  of  a  capital  crime  is,  at  the  time  when  mo- 
tion for  sentence  is  made,  found,  to  the  satisfaction  of  the  court,  to  be  insane,  the  court 
may  cause  such  person  to  be  removed  to  one  of  the  State  lunatic  hospitals  for  such  a 
term  and  under  such  limitations  as  it  may  direct. 

Sec.  35.  If  it  appears  to  the  satisfaction  of  the  governor  and  council  that  a  convict 
under  sentence  of  death  has  become  insane,  the  execution  of  said  sentence  may  be  respited 
by  the  governor,  by  and  with  the  advice  of  the  council,  from  time  to  time  for  stated 
periods,  until  it  appears  to  their  satisfaction  that  the  convict  is  no  longer  insane. 

Removal  of  Insane  Prisoners. 

Chap.  222,  Sec.  id.  The  State  board  of  health,  lunacy  and  cliarity  shall  designate  two 
persons,  expert  in  cases  of  insanity,  to  examine  convicts  in  the  State  prison  or  reformatory 
prison  alleged  to  be  insane.  When  any  such  convict  appears  to  be  insane,  the  warden  or 
superintendent  shall  notify  one  of  the  persons  so  designated,  who  shall,  with  the  physician 
of  the  prison,  examine  the  convict,  and  report  to  the  governor  the  result  of  their  inves- 
tigation. If  upon  such  report  the  governor  deems  the  convict  insane  and  his  removal 
expedient,  he  shall  issue  his  warrant  directed  to  the  warden  or  superintendent,  authorizing 
him  to  cause  the  convict  to  be  removed  to  one  of  the  Slate  lunatic  hospitals,  there  to  be 
kept  until,  in  the  judgment  of  the  superintendent  and  trustees  of  the  hospital  to  which 
he  may  be  committed,  he  should  be  returned  to  prison.  When  the  superintendent  and 
trustees  of  the  hospital  have  come  to  such  judgment,  the  fact  shall  be  certified  upon  the 
warrant  of  the  governor,  and  notice  shall  be  given  to  the  warden  or  superintendent  of 
the  prison,  who'shall  thereupon  cause  the  convict  to  be  reconveyed  to  the  prison,  there  to 
remain  pursuant  to  the  original  sentence,  computing  the  time  of  his  detention  or  confine- 
ment in  the  hospital  as  part  of  the  term  of  his  imprisonment. 

Sec.  12.  When  a  convict  in  a  house  of  correction  or  prison  other  than  the  State  prison 
or  reformatory  prison  appears  to  be  insane,  the  physician  in  attendance  shall  make  a  re- 


646  APPENDIX    A. 

« 
port  thereof  to  the  jailer  or  master,  who  shall  transmit  the  same  to  one  of  the  judges  men- 
tioned in  section  li,  chapter  87.     The  judge  shall  make  inquiry  into   the  facts,  and,  if 
satisfied  that  the  convict  is  insane,  shall  order  his  removal  to  one  of  the  State  lunatic 
hospitals  pursuant  to  the  provisions  of  sections  twelve  and  thirteen  of  said  chapter. 

Sec.  13.  If  any  person  so  removed  becomes  sane  before  the  e.xpiration  of  his  sentence, 
he  shall  be  forthwith  returned  to  the  prison  or  house  of  correction  from  which  he  was 
removed,  there  to  remain,  pursuant  to  his  original  sentence,  computing  the  time  of  his 
confinement  in  the  hospital  as  part  of  the  term  of  his  imprisonment. 

Sec.  14.  When  a  person  held  in  any  jail  for  trial  or  for  sentence,  except  for  a  capital 
crime,  appears  to  be  insane,  he  may  be  removed  to  one  of  the  State  lunatic  hospitals 
as  a  convict  may  be  removed  from  the  house  of  correction  under  section  twelve.  When  a 
person  so  removed  is,  in  the  opinion  of  the  trustees  and  superintendent  of  the  hospital, 
restored  to  sanity,  he  shall  be  forthwith  returned  to  the  jail  from  which  he  was  removed, 
where  he  shall  be  held  in  accordance  with  the  terms  of  the  process  by  which  he  was  orig- 
inally committed  thereto. 

MICHIGAN. 

[See  Public  Acts,  1877,  PP-  215-226,  120, 168,  203,  204.  Public  Acts,  1S81,  pp.  267- 
26g,  247,  139,  231.  Compiled  Laws,  1872,  sees.  4822,  et  seq.  Howell's  annotated  stat- 
utes (i8S2)pp.  513-529-] 

Each  State  asylum  is  under  the  control  of  a  separate  board  of  six  trustees,  appointed 
by  the  governor  with  the  consent  of  the  Senate. 

They  have  power  to  establish  by-laws  regulating  the  conditions  of  admission  and  dis- 
charge of  patients. 

They  are  required  to  maintain  an  "  effective  inspection  "  of  the  asylum,  and  to  visit  it  at 
stated  times. 

When  a  person  in  indigent  circumstances,  and  not  a  pauper,  becomes  insane,  applica- 
tion may  be  made  in  his  behalf  to  the  judge  of  probate  of  the  county  where  he  resides; 
and  said  judge  of  probate  shall  immediately  notify  such  alleged  insane  person  of  such 
application,  and  of  the  time  and  place  of  hearing  to  be  held  thereon ;  he  shall  also  call 
two  respectable  physicians,  and  other  credible  witnesses,  and  also  immediately  notify  the 
prosecuting  attorney  of  the  county,  and  the  supervisor  of  the  township  or  ward  in  which 
such  insane  person  resides,  of  the  time  and  place  of  such  hearing,  whose  duty  it  shall 
be  to  attend  the  examination  and  act  in  behalf  of  said  county;  and  said  judge  of  pro- 
bate shall  fully  investigate  the  facts  in  the  case,  and  either  with,  or  without,  the  verdict 
of  a  jury,  at  his  discretion,  as  to  the  question  of  insanity,  shall  decide  the  case  as  to 
his  indigence,  but  the  decision  of  indigence  shall  not  be  conclusive  in  such  county ; 
and  if  the  judge  of  probate  certifies  that  satisfactory  proof  has  been  adduced,  showing 
him  insane,  and  his  estate  insufficient  to  support  him  and  his  family,  or,  if  he  has  no 
family,  himself,  under  the  visitation  of  insanity,  on  his  certificate  under  the  seal  of  the 
probate  court  of  said  county,  he  shall  be  admitted  into  the  asylum,  and  supported  there 
at  the  expense  of  the  county  to  which  he  belongs,  until  he  shall  be  restored  to  sound- 
ness of  mind,  if  effected  in  two  years,  and  until  otherwise  ordered.  The  judge  of  pro- 
bate in  such  case  shall  have  power  to  compel  the  attendance  of  witnesses  and  jurors, 
and  shall  file  the  certificates  of  the  physicians,  taken  under  oath,  and  other  papers,  in  his 
office,  and  enter  the  proper  order  in  the  journal  of  the  probate  court  in  his  ofiice. 

The  judge  of  probate  shall  report  the  result  of  his  proceedings  to  the  supervisors 
of  his  county,  if  such  person  belongs  to  that  county,  whose  duty  it  shall  be,  at  the 
next  annual  meeting  thereafter,  to  raise  money  requisite  to  meet  the  expenses  of  support 
accordingly. — Public  Acts,  iSSi,  No.  147,  amending  section  26,  of  Act  No.  194  of  ses- 
sion 1877. 

^Vhen  an  insane  person  in  indigent  circumstances  shall  have  been  sent  to  the  asylum 
by  his  friends,  who  have  paid  his  bills  therein  for  three  months,  if  the  superintendent 
shall  certify  he  is  a  fit  patient,  the  supervisors  of  the  county  of  his  residence  are  au- 
thorized and  required,  upon  an  application  under  oath  in  his  behalf,  to  defray  the  ex- 
penses of  his  remaining  there  until  otherwise  ordered. — Public  Acts,  1877,  No.  194,  sec.  29. 

The  relatives  or  friends  of  any  insane  person  may  apply  to  the  judge  of  probate  to  have 
a  guardian  appointed  for  him.  The  judge  shall  cause  fourteen  days'  notice  of  the  hear- 
ng  to  be  given  to  such  alleged  insane  person.     If,  after  full  hearing,  it  appears  to  the 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE.  647 

judge  that  such  person  is  insane  and  incapable  of  taking  care  of  himself  and  manao-- 
ing  his  property,  he  shall  appoint  a  guardian,  who  shall  have  the  care  and  custody  of 
the  person  of  his  ward,  and  the  management  of  his  estate. —  Cojnpiled  Laws,  sees.  4822 
et  seq.,  and  Public  Acts,  1877,  No.  130. 


MINNESOTA. 

[See  Statutes  of  Minnesota  (1878),  pp.  454-459,  598,  958.] 

The  State  Asylum  is  under  the  control  of  a  board  of  seven  trustees,  appointed  by 
the  governor,  with  the  advice  and  consent  of  the  Senate. 

The  probate  judge,  or,  in  his  absence,  the  court  commissioner  of  any  county,  upon  in- 
formation being  filed  before  him  that  there  is  an  insane  person  in  his  county  needing  care 
and  treatment,  shall  cause  the  person  so  alleged  to  be  insane  to  be  examined  by  a  jury 
consisting  of  two  respectable  persons  besides  himself,  one  at  least  of  whom  shall  be  a 
physician,  to  ascertain  the  fact  of  his  insanity ;  and  if  the  said  person  is  found  to  be  in- 
sane, he  shall,  upon  the  written  certificate  of  the  judge,  directed  by  a  majority  of  the  jury, 
issue  duplicate  warrants,  committing  the  person  so  found  insane  to  the  care  of  the  super- 
intendent of  the  hospital,  and  shall  place  the  warrant  in  the  hands  of  the  sheriff",  or  some 
other  suitable  person,  whom  he  shall  authorize  to  convey  the  said  insane  person  to  the 
hospital. —  Ge7ie7-al  Statutes  of  Mhttiesota,  1878,  p.  455. 

The  relatives  of  any  person  charged  with  insanity,  or  who  shall  be  found  to  be  in- 
sane under  section  seventeen  of  this  act,  shall,  in  all  cases,  have  the  right  to  take  charge 
of  and  keep  said  insane  person  or  persons,  if  they  shall  desire  so  to  do,  but  the  pro- 
bate judge  or  court  commissioner  may  require  a  bond  of  such  relatives,  conditioned  for 
the  proper  and  safe  keeping  of  such  person  or  persons ;  and  if  the  relatives  or  friends 
of  any  patient  kept  in  the  hospital,  shall  ask  for  the  discharge  of  such  patient,  the  super- 
intendent may,  in  his  discretion,  require  a  bond  to  be  executed  to  the  State  of  Minne- 
sota, in  such  sum  and  with  such  sureties  as  he  may  deem  proper,  conditioned  for  the 
safe  keeping  of  such  patient :  Provided,  that  no  patient  that  may  be  under  the  charge 
of,  or  convicted  of  homicide,  shall  be  discharged  without  the  consent  of  the  superintend- 
ent and  board  of  trustees. —  General  Statutes  of  Minnesota,  1878,  p.  456. 

The  governor  shall  appoint  two  members  of  the  State  board,  who  shall  serve  for  the 
term  of  one  year,  and  who,  together  with  the  superintendent  of  the  hospital  for  the  in- 
sane, constitute  a  commission,  whose  duty  it  is  to  visit  the  asylum  at  least  once  in  every 
six  months,  to  ascertain  whether  any  persons  are  in  the  asylum  who  ought  not  to  be  there, 
and  are  not  insane,  and,  if  they  find  any  such  to  order  their  discharge. 

The  superintendent  of  the  Minnesota  Hospital  for  the  Insane  is  hereby  required,  on  the 
first  day  of  each  month,  to  make  out  a  report  in  writing,  showing  the  condition  of  each 
patient  in  said  hospital  (separately),  with  reference  to  bodily  health;  appetite;  sleep; 
mental  symptoms,  generally  ;  particular  symptoms  ;  mental  state;  habits  and  inclinations  ; 
prospect  of  restoration;  and  shall  forward  by  mail  to  the  next  of  kin  of  each  of  such 
patients,  respectively,  a  copy  of  such  report,  without  charge,  within  the  first  week  of  each 
month. —  General  Statutes,  i88i,p.  458;   Laws,  1872, chap.  17,^  i. 

In  cases  of  partition  and  division  of  estates,  guardians  are  appointed  for  insane  persons. 


MISSISSIPPI. 

[See  Revised  Code  of  Mississippi,  1880,  chap.  13,  sees.  642-668,  inclusive;  Laws  of 
1882,  pp.  61,  62,  63,  64;  also,  as  to  guardians  for  the  insane,  see  Code,  sees.  21 18-2122, 
inclusive.] 

The  State  Asylum  is  under  the  management  of  a  board  of  five  trustees,  appointed  by  the 
governor.  The  governor  is,  ex  officio,  president  of  the  board.  The  trusteesare  required 
to  keep  a  bound  record  of  all  their  doings,  and  one  or  more  of  them  to  visit  the  asylum 
at  least  once  a  month. 

The  governor  has  the  appointment  and  removal  of  the  medical  superintendent. 

The  superintendent  and  board  of  trustees  may,  upon  application,  receive  a  patient 


648  APPENDIX   A. 

who  they  think  ought  to  be  admitted,  even  though  no  proceedings  in  lunacy  have  been 
instituted. 

It  is  the  duty  of  the  clerk  of  the  chancery  court  of  any  county  where  a  lunatic  is  allowed 
to  be  at  large  to  direct  the  sheriff  by  writ  of  lunacy  to  summon  the  alleged  lunatic,  and 
six  discreet  persons  to  make  inquisition  thereto. 

If  such  inquest,  or  a  majority  of  them,  adjudge  that  such  person  is  a  lunatic,  he  shall  be 
committed  to  the  asylum. 

The  chancery  courts  of  the  State  may  order  an  inquisition  and  appoint  a  guardian  for 
any  insane  person.  Such  guardian  has  the  care  of  the  person  and  estate  of  the  lunatic, 
and  must  give  bonds,  and  is  accountable  to  and  under  the  control  of  the  courts. 


MISSOURI. 

[See  Revised  Statutes  of  Missouri  (1879),  sees.,  4102-4159,  5787-5837.  Laws  of 
i88x,  pp.  123,  141.     Laws  of  1883,  pp.  78,  79.] 

The  State  lunatic  asylum  is  under  the  control  and  direction  of  a  board  of  nine 
managers,  three  of  whom  shall  be  competent  physicians,  appointed  by  the  governor, 
with  the  advice  and  consent  of  the  Senate. 

Two  of  the  managers  shall,  together,  visit  the  asylum  monthly ;  a  majority  of  them, 
together,  quarterly;  and  all  the  managers,  together,  shall  make  a  visit  once  a  year. 

Pay  patients,  or  those  not  sent  to  the  asylum  by  order  of  the  court,  may  be  admitted  on 
such  terms  as  shall  be,  by  this  chapter  and  the  by-laws  of  the  asylum,  prescribed  and 
regulated. — Revised  Statutes,  sec.  41 19. 

Preparatory  to  the  admission  of  such  a  patient,  the  superintendent  shall  be  furnished 
with  a  request,  of  the  form  seen  in  section  four  thousand  one  hundred  and  twenty-one, 
under  the  hand  of  the  person  by  whose  direction  he  is  sent,  stating  his  age  and  place 
of  nativity,  if  known,  his  christian  and  surname,  place  of  residence,  occupation,  and 
degree  of  relationship  or  other  circumstances  of  connection  between  him  and  the  per- 
son requesting  his  admission  ;  and,  second,  a  certificate  of  the  form  seen  in  section  four 
thousand  one  hundred  and  twenty-two,  dated  within  two  months,  under  oath,  signed  by 
two  physicians,  of  the  fact  of  his  being  insane. 

Each  person,  signing  such  request  or  certificate,  shall  annex  to  his  name  his  profession 
or  occupation,  and  the  township,  county,  and  State  of  his  residence,  unless  these  appear 
on  the  face  of  the  document.  Before  any  private  patient  shall  be  received  into  the  asylum, 
there  shall  be  produced  to  the  superintendent  a  receipt  from  the  treasurer  of  the  asylum, 
acknowledging  the  payment  to  him  of  at  least  thirty  days'  charges  in  advance,  and  a  suf- 
ficient bond  to  said  treasurer,  conditioned  tliat  the  obligor  or  obligors  will  secure  the  pay- 
ment of  charges  incurred  in  behalf  of  and  on  account  of  said  patient ;  said  bond,  with 
satisfactory  securities,  shall  be  of  the  form  and  contain  the  provisions  as  provided  in 
section  four  thousand  one  hundred  and  twenty-three. 

No  part  of  said  thirty  days'  payment  shall  be  refunded  if  the  patient  making  such  pay- 
ment shall  be  taken  away  within  that  period,  uncured,  and  against  the  consent  of  the  su- 
perintendent.— -Revised  Statutes,  sec.  4120. 

Form  of  Request  for  Admission. 

To  the  Superintendent  of  the  Missouri  State  Lunatic  Asylum  : 

The  undersigned,  of  the  county  of  ,  is  desirous  of  placing  in  the  State  Lunatic 

Asylum,  at  Fulton,  and  hereby  requests  the  admission  therein,  of ,  a  resident  of 

the  county  of  ,  who  is  aged  — ,  and  has  been  [here  state  what  the  occupation  of 

the  person  has  been].     He  [or  she]  is  a  native  of  ,  in  the  State  of  ,  and 

is  [here  state  what  the  relationship  or  circumstances  of  connection  may  be]  of  the  under- 
signed ;  [then  should  follow  a  written  history  of  the  case,  including  the  alleged  cause  of 
insanity,  when  it  commenced,  and  all  the  particulars  thereof.] 

Dated, day  of  ,   18 — . 

Form  of  Physician's  Certificate. 
State  of ") 

County  of' .  \^^' 

We,  ,  and  ,  of  the  County  and   State  aforesaid,  physicians,  do 

hereby  certify  that  we  have  this  day  seen  and  examined  [here  insert  the  name  of  the 


ABSTRACT  OF  LAWS  RELATING  TO  THE  INSANE.        649 

patient],  of  the  county  of ,  and  believe  —  to  be  insane,  and  a  proper  patient 

to  be  sent  to  the  State  lunatic  asylum. 


(Signed) 


The  above  named,  ,  and  ,  being  duly  sw^orn,  say  that  they  are  prac- 
ticing physicians,  of  the  county  aforesaid,  and  that  the  facts  stated  in  the  above  certifi- 
cate, by  them  subscribed,  are  true,  according  to  the  best  of.  their  knowledge  and  belief. 

(Signed)  ^^^^  ' 

Sworn  to  and  subscribed  before  me,  this day  of  ,  18 — . 

,  J.  P. 

Patients  may  be  sent  by  the  county  court  to  said  asylum,  upon  application  or  state- 
ment filed  with  the  clerk  of  the  county  court,  stating  insanity,  indigence,  etc.,  and  after 
proper  investigation  before  the  court,  or  court  and  jury,  and  examination  of  witnesses, 
including  at  least  one  physician. 

After  trial  by  jury  in  the  probate  court,  a  guardian  may  be  appointed  of  the  person 
and  estate  of  the  person  so  found  to  be  insane. — -See  Revised  Statutes,  sees.  5787,  5837. 


NEBRASKA. 

[See  Compiled  Statutes  of  Nebraska  (Guy  A.  Brown,  1881),  chap.  40,  pp.  300-308, 
and  p.  292;  Appendix  to  same,  chap.  40,  p.  867;  Laws  of  Neb.,  1883,  chaps.  48  and  49, 
pp.  234  and  235.] 

The  State  hospital,  located  at  Lincoln,  is  under  the  charge  of  three  trustees,  but  the 
governor  of  the  State  appoints  the  superintendent,  and  may  appoint  two  assistant 
physicians,  one  of  whom  shall  be  a  woman. — See  Compiled  Stats.,  p.  300,  and  App.,  p. 
897. 

In  each  county  there  shall  be  a  board  of  three  commissioners,  composed  of  the  clerk 
of  the  district  court,  a  physician,  and  a  lawyer.  Said  commissioners  regulate  admissions 
to  the  asylum  and  the  general  safe-keeping  of  insane  persons  within  their  county. 

Upon  the  filing  of  an  information  with  affidavit,  alleging  the  insanity  of  the  person  in 
whose  behalf  the  application  is  made,  the  commissioners  will  make  an  investigation. 
They  have  power  to  subpcena  witnesses,  administer  oaths,  and  do  any  act  of  a  court 
necessary  in  the  premises.  A  physician  (who  may  be  one  of  their  own  number)  must  be 
appointed  to  examine  the  patient  and  make  a  certificate.  The  person  alleged  to  be  insane 
may  appear  and  resist  the  application,  and  the  parties  may  be  represented  by  counsel. 

If  the  commissioners  find  that  the  person  alleged  to  be  insane  is  insane,  and  a  fit  subject 
for  treatment,  they  may  issue  a  warrant  and  cause  his  removal  to  the  asylum.  No  female 
person  shall  be  thus  taken  to  the  hospital  without  the  attendance  of  some  other  female, 
or  some  relative  of  such  person,  and  the  friends  or  relatives  of  any  person  so  found  insane 
have  the  privilege  of  executing  the  warrant  of  removal  to  the  asylum  instead  of  the 
sheriff,  if  they  so  request  — See  Compiled  Stats.,  pp.  302-303. 

In  each  case  of  application  for  admission  to  hospital,  correct  answers,  so  far  as  possible, 
to  a  series  of  questions  pi^ovided  by  the  statute  must  accompany  the  physician's  certificate. 

No  person  supposed  to  be  insane  shall  be  restrained  of  his  or  her  liberty  by  any  other 
person,  otherwise  than  in  pursuance  of  authority  obtained  as  herein  required,  excepting 
to  such  extent  and  for  such  brief  period  as  may  be  necessary  for  the  safety  of  persons  and 
property,  until  such  authority  can  be  obtained. 

Any  person  having  care  of  an  insane  person  and  restraining  such  person,  either  with 
or  without  authority,  who  shall  treat  such  person  with  wanton  severity,  or  harshness,  or 
cruelty,  or  shall  in  any  way  abuse  such  person,  shall  be  guilty  of  a  misdemeanor,  besides 
being  liable  in  an  action  for  damages. —  Coinpiled  Stats.,  p.  305. 

Privileges  of  Inmates. 

That  henceforth  there  shall  be  no  censorship  exercised  over  the  correspondence  of 
inmates  of  the  hospital  for  the  insane  in  this  State,  but  their  post-office  rights  shall  be  as 
free  and  unrestrained  as  are  those  of  any  resident  or  citizen  of  this  State,  and  be  under  the 


650 


APPENDIX   A. 


protection  of  the  same  postal  laws.  And  every  inmate  shall  be  allowed  to  write  when 
and  whenever  he  or  she  desires  to  any  person  he  or  she  may  choose.  And  it  is  hereby 
made  the  duty  of  the  superintendent  to  furnish  each  and  every  inmate  of  each  and  every 
insane  asylum  in  this  State  with  suitable  material,  at  the  expense  of  the  State,  for  writing, 
inclosing,  sealing,  stamping,  and  mailing  letters,  sufficient  for  writing  at  least  one  letter 
a  week,  provided  they  request  the  same,  unless  they  are  otherwise  furnished  with  such 
material ;  and  all  such  letters  shall  be  dropped  by  the  writers  thereof,  accompanied  by 
an  attendant  when  necessary,  into  a  post-office  box,  provided  by  the  State  at  the  hospital 
for  the  insane,  and  kept  in  some  place  easy  of  access  to  all  the  patients  ;  and  the  contents 
of  such  post-office  box  or  boxes  shall  be  collected  once  every  week  by  an  authorized 
person,  and  by  him  placed  into  the  hands  of  the  United  States  mail  for  delivery.  And 
it  is  hereby  made  the  duty  of  the  superintendent  of  every  hospital  for  the  insane  in  this 
State,  either  public  or  private,  to  deliver,  or  cause  to  be  delivered,  to  said  person  any 
letter  or  writing  to  him  or  her  directed,  without  opening  or  reading  the  same,  or  allowing 
it  to  be  opened  or  read,  without  the  consent  of  the  recipient  of  such  letter,  or  the  request 
or  the  consent  of  the  writer. 

[Section  one  of  "An  act  for  the  protection  of  the  inmates  of  the  hospital  for  the  in- 
sane," took  effect  February  27,  1883.] — See  Appc7idix  io  Compiled  Stats.,  p.  867;  and 
Gen.  Laws,  1882-3,  chap.  40,  p.  300. 

Penalty. 

That  any  person  refusing  or  neglecting  to  comply  with,  or  wilfully  and  knowingly 
violating,  any  of  the  provisions  of  this  act,  shall,  upon  conviction  thereof,  be  punished 
by  imprisonment  in  the  penitentiary  for  a  time  not  exceeding  three  years  nor  less  than 
six  months,  or  by  a  fine  not  exceeding  five  hundred  dollars,  or  both,  at  the  discretion  of 
the  court,  and  by  ineligibility  to  any  office  in  the  asylum  afterward. — Id.,  \  2. 

Act  to  be  Posted. 

A  printed  copy  of  this  act  shall  be  framed  and  kept  posted  in  every  ward  of  every 
hospital  for  the  insane,  both  public  and  private,  in  the  Slate  of  Nebraska. — Id.,  §  3. 

Upon  proper  proceedings,  guardians  may  be  appointed  for  the  insane  by  the  probate 
court. — See  Compiled  Stats.,  p.  292. 


NEVADA. 

[See  Compiled  Laws  of  Nevada  (1873),  sees.  3740-3745,  and  sec.  845;  Statutes  of 
Nevada,  1S81,  chap.  42,  p.  59;   Stats,  of  Nev.,  18S3,  chap.  76,  p.  102.] 

A  board  of  commissioners,  consisting  of  the  governor,  lieutenant-governor,  State 
controller.  State  treasurer,  and  two  others,  has,  by  statute,  the  full  power  and  exclusive 
control  over  the  State  asylum. 

Upon  the  application  of  any  person  under  oath  to  the  judge  of  the  district  court, 
setting  forth  that  any  persoir  is  insane,  said  judge  shall  cause  such  person  to  be  brought 
before  him,  and  shall  also  summon  one  or  more  licensed  practicing  physicians,  who  shall 
proceed  to  examine  the  person  alleged  to  be  insane.  If  said  physicians  shall,  after  a 
careful  examination,  certify  upon  oath  that  the  charge  is  correct,  and  the  judge  is  satisfied 
that  it  is  unsafe  for  such  person  to  be  at  large,  he  shall  cause  such  insane  person  to  be 
committed  to  the  asylum.  If  such  person  is  indigent  and  without  relatives  in  the  State, 
his  support  at  the  asylum  shall  be  at  the  expense  of  the  State.  Paying  patients  shall  pay 
according  to  the  terms  directed  by  the  board  of  commissioners;  but  the  statute  provides 
that  the  insane  poor  shall,  in  all  respects,  receive  the  same  medical  care  and  treatment 
and  good,  wholesome  food. — Lazvs  of  1881,  chap.  42. 

Upon  application  and  proper  proceedings  before  the  probate  judge,  a  guardian  may 
be  appointed  of  the  person  and  estate  of  any  person  who  shall  appear  to  be  insane  and 
incapable  of  taking  care  of  himself  and  managing  his  property. — Cofiipiled  laws,  p,  206, 
sees.  845  et  seq. 


ABSTRACT    OF    LAWS    RELATING   TO   THE    INSANE.  65 1 


NEW  HAMPSHIRE. 

[General  Laws  of  New  Hampshire  (1878),  chap.  10.] 

The  Asylum  for  the  Insane. 

Section  i.  The  asylum  for  the  insane  at  Concord  is  a  corporation  under  the  name  of 
the  New  Hampshire  Asylum  for  the  Insane. 

Sec..  2.  The  government  of  the  asylum  is  vested  in  twelve  trustees,  appointed  and 
commissioned  by  the  governor,  with  advice  of  the  council;  and  all  vacancies  shall  be 
filled  in  the  same  manner. 

Sec.  7.  The  trustees  may  make  such  regulations  for  their  own  government,  for  the 
management  of  the  asylum  and  all  persons  connected  therewith,  and  for  the  admission 
and  care  of  patients,  and  the  same,  from  time  to  time,  alter,  as  convenience  may  require. 
Sec.  9  (abst.).  The  trustees  shall  report  annually  to  the  governor  and  council. 
Sec.  id.  The  governor  and  council,  president  of  the  Senate  and  speaker  of  the 
House  shall  constitute  a  board  of  visitors  of  the  asylum ;  shall  visit  and  inspect  the  same 
when  necessary ;  examine  into  the  condition  of  the  patients,  and  the  regulations  and 
general  management  of  the  asylum ;  see  that  the  design  thereof  is  carried  into  full 
effect ;  and  make  to  the  legislature,  biennially,  a  report,  which  shall  be  furnished  to  the 
secretary  of  state  on  or  before  the  20th  day  of  April  next  before  the  June  session. 

Sec.  12.  If  any  insane  person  is  in  such  condition  as  to  render  it  dangerous  that  he 
should  be  at  large,  the  judge  of  probate,  upon  petition  by  any  person,  and  such  notice  to 
the  selectmen  of  the  town  in  which  such  insane  person  is,  or  to  his  guardian  or  any 
other  person,  as  he  may  order, — which  petition  may  be  filed,  notice  issued,  and  a  hear- 
ing had  in  vacation  or  otherwise, — may  commit  such  insane  person  to  the  asylum. 

Sec.  13.  If  any  insane  person  is  confined  in  any  jail,  the  supreme  court  may  order 
him.  to  be  committed  to  the  asylum,  if  they  think  it  expedient. 

Sec.  14.  Any  insane  pauper  supported  by  any  town  may  be  committed  to  the  asylum 
by  order  of  the  overseers  of  the  poor,  and  there  supported  at  the  expense  of  such  town  ; 
and  such  expense  may  be  recovered  by  such  town  of  the  county,  town,  or  person 
chargeable  with  the  support  of  such  pauper,  in  the  same  manner  as  if  he  had  been  sup- 
ported in  and  by  the  town. 

Sec.  15.  If  the  overseers  neglect  to  make  such  order  in  relation  to  any  insane  county 
pauper,  the  supreme  court,  or  any  two  judges  thereof  in  vacation,  may  order  such 
pauper  to  be  committed  to  the  asylum,  and  there  supported  at  the  expense  of  the 
county. 

Sec.  16.  Any  insane  person  committed  to  the  asylum  by  order  of  the  supreme  court, 
such  person  having  been  charged  with  an  offence  the  punishment  whereof  as  prescribed 
by  law  is  death  or  confinement  in  the  State  prison,  shall,  during  his  confinement  in  the 
asylum  for  the  insane,  be  supported  therein  at  the  expense  of  the  State.  Any  insane 
person  committed  to  the  asylum  by  any  court,  except  as  herein  provided,  or  by  any  judge 
of  probate,  sliall  be  supported  by  the  county  from  which  he  was  committed. 

Sec.  17.  The  parent,  guardian,  or  friends  of  any  insane  person  may  cause  him  to  be 
committed  to  the  asylum,  with  the  consent  of  the  trustees,  and  there  supported  on  such 
terms  as  they  may  agree  ;  but  the  city  of  Concord  shall  not,  in  any  case,  be  liable  for 
the  support  or  maintenance  of  any  person  committed  to  said  asylum,  except  from  said 
city. 

Sec.  18.  No  person  shall  be  committed  to  the  asylum  for  the  insane,  except  by  the 
order  of  the  court  or  the  judge  of  probate,  without  the  certificate  of  two  reputable  physi- 
cians that  such  person  is  insane,  given  after  a  personal  examination  made  within  one 
week  of  tlie  committal ;  and  such  certificate  shall  be  accompanied  by  a  certificate  from 
a  judge  of  the  supreme  court  or  court  of  probate,  or  mayor,  or  chairman  of  the  select- 
men, testifying  to  the  genuineness  of  the  signatures  and  the  respectability  of  the  signers. 
Secs.  19,  20  and  21  (abst.).  Person  committed  shall  be  supported  by  his  county  if  with- 
out means  or  relatives  of  sufficient  ability. 

Sec.  22.  Any  person  committed  to  the  asylum  may  be  discharged  by  any  three  of 
the  trustees,  or  by  any  justice  of  the  supreme  court,  whenever  the  cause  of  commit- 
ment ceases  or  a  further  residence  at  the  asylum  is,  in  their  opinion,  not  necessary ;  but 
any  person  so  discharged,  who  was  under  sentence  of  imprisonment  at  the  time  of  his 
commitment,  the  period  of  which  shall  not  have  expired,  shall  be  remanded  to  prison. 


652  APPENDIX    A. 

Sec.  23.  Some  one  of  the  board  of  trustees  of  the  asyhim  shall,  without  previous 
notice,  visit  the  institution  at  least  twice  every  month,  and  give  suitable  opportunity  to 
every  patient  therein  who  may  desire  it  to  make  to  him,  in  private,  any  statements  such 
patients  may  wish  to  make ;  and,  whenever  in  his  opinion  it  may  be  deemed  proper, 
he  shall  call  to  his  aid  two  other  members  of  said  board,  who  shall,  with  him,  make  a 
further  examination  of  such  patient  and  of  the  statements  by  him  made.  If,  in  their 
view,  the  cause  of  commitinent  no  longer  exists,  or  a  further  residence  at  the  asylum  is 
not  necessary,  it  shall  be  their  duty  to  discharge  such  patient.  Should  they  deem  the 
treatment  of  any  patient  injudicious,  they  shall  order  such  an  immediate  change  of  the 
same  as  to  them  seems  proper;  and,  in  case  of  failure  to  secure  it,  they  shall  at  once 
summon  a  meeting  of  the  whole  board,  whose  duty  it  shall  be  to  take  such  measures  as 
the  exigency  of  the  case  demands. 

Sec.  24.  It  shall  be  the  duty  of  the  superintendent  to  furnish  stationery  to  any  patient 
who  may  desire  it,  and  to  transmit  any  letter  such  patient  may  address  to  the  board  of 
trustees,  to  such  member  as  said  board  shall  have  designated  to  receive  such  correspond- 
ence, and  all  such  letters  shall  be  promptly  transmitted  without  inspection. 

Sec.  25.  In  event  of  the  sudden  death  of  any  patient  in  the  asylum,  a  coroner's  inquest 
shall  be  held,  as  provided  for  by  law  in  other  cases. 

Sec.  27.  The  governor,  with  the  advice  of  the  council,  may  remove  to  the  asylum,  to 
be  there  kept  at  the  expense  of  the  State,  any  person  confined  in  the  State  prison  who  is 
insane. 

Sec.  28.  The  sum  of  six  thousand  dollars  is  annually  appropriated  for  the  maintenance 
of  indigent  insane  persons  belonging  to  this  State  at  the  asylum,  for  such  and  so  many  as 
the  governor  may  from  time  to  time  approve,  not  less  than  two-thirds  of  which  sum  shall 
be  applied  annually  to  the  support  of  private  patients  exclusive  of  paupers  maintained  at 
public  charge;  and  the  sum  of  one  hundred  dollars  is  annually  appropriated  toward  the 
support  and  increase  of  the  library  for  the  insane. 

Laws  of  j88i,  Chapter  1^0. 

Joint  Resolution  Authorizing  the  Governor  to  Appoint  Suitable  Persons 
TO  Examine  into  the  Condition  of  Insane  Persons  in  the  County  Alms- 
houses in  this  State. 

Resolved,  by  the  Senate  and  House  of  Representatives ,  in  General  Assembly  convened : 

That  the  governor,  with  the  advice  of  the  council,  shall,  on  or  before  the  first  day  of 
October  next,  appoint  three  competent  persons,  of  whom  one  shall  be  a  physician,  one  a 
lawyer,  and  the  third  a  mair  of  general  business  experience,  whose  duty  it  shall  be  to 
visit  the  several  county  almshouses  in  the  State,  examine  into  the  condition  of  every 
insane  person  there  detained;  and  report  to  the  governor  and  council,  on  or  before  the 
first  day  of  May,  1S83,  the  number,  condition,  the  manner  of  care,  and  treatment  of  all 
such  persons,  together  with  such  recommendations  relative  to  a  modification  or  improve- 
ment of  the  same  as  from  their  investigations  they  may  deem  necessary;  which  report, 
with  such  suggestions  as  he  may  think  advisable,  the  governor  shall  cause  to  be  printed 
and  laid  before  the  legislature  at  its  next  session. 

The  persons  so  appointed  shall  receive  no  compensation  for  their  services,  but  shall  be 
paid  their  necessary  travelling  expenses  from  the  treasury  of  the  State. 

(Approved  August  18,  1881.) 

Laws  of  iSyg,  Chapter  g2. 

Joint  Resolution  relating  to  the  Price  of  Board  in  the  Asylum  for 

the  Insane. 

Resolved,  by  the  Senate  and  House  of  Representatives,  in  General  Assembly  convened : 

The  governor  and  council  are  hereby  directed  to  take  immediate  steps  to  cause  a 
reduction  in  the  board  at  the  insane  asylum  to  four  dollars  per  week :  Provided,  That 
this  resolution  shall  not  be  construed  to  forfeit  the  charge  and  payment  for  necessary 
attendance  and  expense  required  by  any  patient  in  case  of  severe  sickness  or  accident. 

(Approved  July  19,  1879.) 


ABSTRACT    OF    LAWS    RELATING   TO   THE    INSANE.  653 


NEW  JERSEY. 

No  person  shall  be  admitted  into  the  State  asylum  for  the  insane  unless  by  order  of 
some  court  or  judge  authorized  to  send  patients,  without  lodging  with  the  superintendent. 
First,  a  request  for  admission,  under  the  hand  of  the  person  by  whose  direction  he  is  sent, 
stating  his  age,  place  of  nativity,  residence,  occupation,  degree  of  relationship,  etc.,  and 
second,  a  certificate  dated  within  one  month,  under  oath,  signed  by  one  respectable  phy- 
sician.— New  Jersey  Revision,  1877,  sec.  17,  page  623. 

Insane  paupers  may  be  sent  to  State  asylum  by  order  of  court  after  examination  and 
certificate  of  one  physician  called  by  the  court,  and  are  supported  by  the  county  of  their 
residence. 

Persons  in  indigent  circumstances,  not  paupers,  may,  upon  application  to  the  court  and 
after  investigation  and  examination  by  one  reputable  physician  called  by  the  court,  and 
either  with  or  without  the  verdict  of  a  jury,  be  sent  to  the  State  asylum  and  supported  at 
the  expense  of  the  county. — New  Jersey  Revision,  1877,  p.  624. 

When  a  person  shall  have  escaped  indictment  or  have  been  acquitted  of  a  criminal 
charge  upon  trial  on  the  ground  of  insanity,  the  court  shall  inquire  whether  his  insanity 
in  any  degree  continues,  and  if  it  does  shall  order  him  into  safe  custody. — New  Jersey 
Revision,  1877,  p.  625. 

Persons  confined  in  jail  who  shall  appear  to  be  insane  may,  after  proper  investigations 
and  proceedings,  be  sent  by  the  court  to  the  insane  asylum. — Ibid.,  p.  625. 

Any  two  justices  of  the  peace  of  the  county  in  which  any  lunatic  too  furiously  mad  or 
dangerous  to  be  permitted  to  go  at  large  shall  be  found,  may  cause  such  person  to  be  ap- 
prehended and  kept  safely  locked  up  and  chained  if  necessary  in  some  secure  place  until 
the  last  legal  settlement  of  such  person  can  be  ascertained;  or  if  such  information  cannot 
be  obtained  such  person  may  be  conveyed  to  any  place  in  the  county  provided  for  the 
reception  of  maniacs  or  lunatics,  or,  in  the  absence  of  such  place,  may  be  conveyed  to 
the  county  jail. 

This  not  to  restrain  or  abridge  the  power  or  authority  of  the  chancellor,  orphans' 
court,  or  guardian  touching  such  person,  or  to  prevent  any  friends  or  relatives  of  such 
person  from  taking  him  under  their  protection.— A^w  Jersey  Revision,  1877,  p.  605. 

Board  of  managers  to  maintain  effective  inspection  of  the  State  asylum,  and  one  or 
more  of  them  to  visit  it  at  least  once  a  week,  two  or  more  at  least  once  a  month,  a  ma- 
jority at  least  once  in  three  months,  and  the  whole  board  once  a  year  at  the  times  and  in 
the  manner  prescribed  in  the  by-laws.  Managers  to  note  in  a  bound  book  their  visits, 
with  remarks,  and  this  to  be  inserted  in  their  annual  report  to  the  governor. — New  Jer- 
sey Revision,  p.  622.  ^ 

NEW  YORK. 

[See  Laws  of  1874,  chap.  446;  Laws  of  1875,  chap.  574;  Laws  of  1876,  chap.  267  ; 
Laws  of  1878,  chap.  47  ;  Laws  of  1880,  chap.  423;  New  York  Revised  Statutes  (sixth 
edition.  Banks  Bros.),  vol.  ii.,  page  841,  et  seq. ;  New  York  Code,  Civil  Procedure,  sees. 
2320-2364,  and  1590;  New  York  Penal  Code,  sees.  377  and  445.] 

Commitment  of  the  Insane. 
Laws  of  1874,  Chapter  44.6,  Article  /, 

Section  i.  No  person  shall  be  committed  to  or  confined  as  a  patient  in  any  asylum, 
public  or  private,  or  in  any  institution,  home,  or  retreat,  for  the  care  and  treatment  of  the 
insane,  except  upon  the  certificate  of  two  physicians,  under  oath,  setting  forth  the  insanity 
of  such  person.  But  no  person  shall  be  held  in  confinement  in  any  such  asylum  for  moi-e 
than  five  days,  unless  within  that  time  such  certificate  be  approved  by  a  judge  or  justice 
of  a  court  of  record  of  the  county  or  district  in  which  the  alleged  lunatic  resides,  and 
said  judge  or  justice  may  institute  inquiry  and  take  proofs  as  to  any  alleged  lunacy  before 
approving  or  disapproving  of  such  certificate,  and  said  judge  or  justice  may,  in  his  dis- 
cretion, call  a  jury  in  each  case  to  determine  the  question  of  lunacy. 

Sec.  2.  It  shall  not  be  lawful  for  any  physician  to  certify  to  the  insanity  of  any  person 
for  the  purpose  of  securing  his  commitment  to  an  asylum,  unless  said  physician  be  of 


654 


APPENDIX   A. 


reputable  character,  a  graduate  of  some  incorporated  medical  college,  a  permanent  resi- 
dent of  the  State,  and  shall  have  been  in  the  actual  practice  of  his  profession  for  at  least 
three  years,  and  such  qualifications  shall  be  certified  to  by  a  judge  of  any  court  of  record. 
No  certificate  of  insanity  shall  be  made  except  after  a  personal  examination  of  the  party 
alleged  to  be  insane,  and  according  to  forms  prescribed  by  the  State  commissioner  in 
lunacy,  and  every  such  certificate  shall  bear  date  of  not  more  than  ten  days  prior  to  such 
commitment. 

Sec.  3.  It  shall  not  be  lawful  for  any  physician  to  certify  to  the  insanity  of  any  person 
for  the  purpose  of  committing  him  to  an  asylum  of  which  the  said  physician  is  either  the 
superintendent,  proprietor,  an  officer  or  a  regular  professional  attendant  therein. 

Sec.  4.  Every  superintendent  of  a  State  asylum  or  public  or  private  asylum,  institu- 
tion, home,  or  retreat  for  the  care  and  treatment  of  the  insane,  shall,  within  three  days 
after  the  reception  of  any  patient,  make  or  cause  to  be  made,  a  descriptive  entry  of  such 
case  in  a  book  exclusively  set  apart  for  that  purpose.  He  shall  also  make  entries  from 
time  to  time  of  the  mental  state,  bodily  condition,  and  medical  treatment  of  such  patient, 
together  with  the  forms  of  restraint  employed,  during  the  time  such  patient  remains 
under  his  care,  and  in  the  event  of  the  discharge  or  death  of  such  patient,  the  superin- 
tendent aforesaid  shall  state  m  such  case-book  the  circumstances  appertaining  thereto. 

Sec.  5.  The  county  superintendents  of  the  poor  of  any  county  or  town,  to  which  any 
person  shall  be  chargeable,  who  shall  be,  or  shall  become  a  lunatic,  may  send  any  such 
person  to  any  State  lunatic  asylum  by  an  order  under  their  hands,  and  in  compliance  with 
the  provisions  of  this  act. 

Sec.  6.  In  case  of  the  refusal  or  neglect  of  any  committee  or  guardian  of  any  lunatic, 
or  his  relatives,  to  confine  and  maintain  him,  or  where  there  is  no  such  committee,  guar- 
dian, or  relative  of  sufficient  ability  to  do  so,  it  shall  be  the  dut)^  of  the  overseers  of  the 
poor,  or  constables  of  the  city  or  town  where  any  lunatic  shall  be  found,  to  report  the 
same  forthwith  to  the  superintendent  of  the  poor,  who  shall  apply  to  the  county  judge, 
special  county  judge  or  suri-ogate,  who,  upon  being  satisfied  upon  examination  that  it 
would  be  dangerous  to  permit  such  lunatic  to  go  at  large,  shall  issue  his  warrant,  directed 
to  the  constables  and  overseers  of  the  poor  of  such  city  or  town,  commanding  them  to 
cause  such  lunatic  to  be  apprehended  and  to  be  sent  within  the  next  ten  days  to  some 
State  lunatic  asylum,  or  to  such  public  or  private  asylum  as  may  be  approved  by  any 
standing  order  or  resolution  of  the  supervisors  of  the  county,  to  be  there  kept  and  main- 
tained until  discharged  by  law. 

Sec.  7.  It  shall  be  the  duty  of  the  overseers  of  the  poor  or  constables  to  whom  such 
warrant  shall  be  directed,  to  procure  a  suitable  place  for  the  confinement  of  such  lunatic 
as  therein  directed  pursuant  to  the  preceding  section,  but  in  no  case  shall  any  lunatic  be 
contined  in  any  other  place  than  a  State  lunatic  asylum  or  a  public  or  private  asylum 
duly  approved  as  aforesaid,  for  a  longer  period  than  ten  days. 

Sec.  8.  No  person,  who  by  reason  of  lunacy  or  otherwise,  is  so  far  disordered  in  his 
mind  as  to  be  dangerous  to  himself  or  others  shall  be  committed  as  a  disorderly  person 
to  any  prison,  jail,  house  of  correction,  or  confined  therein  unless  an  agreement  shall 
have  been  made  for  that  purpose  with  the  keeper  thereof;  and  no  such  lunatic  or  person 
disordered  in  his  mind  shall  be  confined  in  the  same  room  with  any  person  charged  with 
or  convicted  of  any  crime,  nor  shall  such  lunatic  be  confined  in  any  prison,  jail  or  house 
of  correction  for  more  than  ten  days. 

Sec.  9.  If  any  person  being  of  disordered  mind  and  committed  as  a  dangerous  lunatic 
to  any  prison,  jail,  or  house  of  correction  as  set  forth  in  the  preceding  section  shall  con- 
tinue to  be  insane  at  the  expiration  of  ten  days  he  shall  be  sent  forthwith  to  some  State 
lunatic  asylum,  or  to  such  public  or  private  asylum  as  may  be  approved  as  aforesaid. 

Sec.  10.  Any  overseer  of  the  poor,  constable,  keeper  of  a  jail,  or  other  person,  who 
shall  confine  any  lunatic  in  any  other  manner,  or  in  any  other  place  than  such  as  are  herein 
specified,  shall  be  deemed  guilty  of  a  misdemeanor,  and  on  conviction  thereof  shall  be 
liable  to  a  fine  not  exceeding  two  hundred  and  fifty  dollars,  or  to  imprisonment  not  ex- 
ceeding one  year,  or  to  both,  at  the  discretion  of  the  court  before  which  the  conviction 
shall  be  had. 

Sec.  II.  If  any  lunatic,  committed  under  the  provisions  of  this  article,  or  any  friend 
in  his  behalf,  be  dissatisfied  with  any  final  decision  or  order  of  a  county  judge,  special 
county  judge,  surrogate,  judge  of  the  superior  court,  or  court  of  common  pleas  of  a  city, 
or  police  magistrate,  he  may,  within  three  days  after  such  order  or  decision,  appeal  there- 
from to  a  justice  of  the  supreme  court,  who  shall,  thereupon,  stay  his  being  sent  out  of 
the  county,  and  forthwith  call  a  jury  to  decide  upon  the  fact  of  lunacy.  After  a  full  and 
fair  investigation,  aided  by  the  testimony  of  at  least  two  respectable  physicians,  if  such 


ABSTRACT    OF    LAWS    RELATING   TO    THE    INSANE,  655 

jury  find  him  sane,  the  justice  shall  forthwith  discharge  him,  or,  otherwise,  he  shall  con- 
firm the  order  for  his  being  sent  immediately  to  an  asylum.  In  case  any  county  judge, 
special  county  judge,  surrogate,  judge  of  the  superior  court  or  common  pleas  of  a  city,  or 
police  magistrate,  refuses  to  malce  an  order  for  the  confinement  of  any  insane  person 
proved  to  be  dangerous  to  himself  or  others  if  at  large,  he  shall  state  his  reasons  for  such 
refusal  in  writing,  so  that  any  person  aggrieved  may  appeal  therefrom  to  a  justice  of  the 
supreme  court,  who  shall  hear  and  determine  the  matter  in  a  summary  way,  or  call  a 
jury,  as  he  may  think  most  fit  and  proper. 

Sec.  12.  If  such  lunatic  is  not  possessed  of  sufficient  property  to  maintain  himself, 
it  shall  be  the  duty  of  the  father,  mother,  or  children  of  such  lunatic,  if  of  sufficient 
ability,  to  provide  a  suitable  place  for  his  confinement,  and  to  confine  and  maintain  him 
in  such  manner  as  shall  be  agreeable  to  the  provisions  of  this  act.  But  in  case  his  rela- 
tives are  not  of  sufficient  ability  to  maintain  him,  then  the  superintendent  of  the  poor  of 
the  county  shall,  upon  his  order,  send  such  pauper  lunatic  to  any  State  asylum,  or  to  such 
public  or  private  asylum  as  may  be  approved  by  a  standing  order  or  resolution  of  the 
supervisors,  within  ten  days. 

Sec.  13.  The  overseers  and  superintendents  of  the  poor  shall  have  the  same  remedies  to 
compel  such  relatives  to  confine  and  maintain  such  lunatic,  and  to  collect  the  costs  and 
charges  of  his  confinement,  as  are  given  by  law  in  the  case  of  poor  and  iinpotent  persons 
becoming  chargeable  to  any  town. 

Sec.  14.  When  a  person  in  indigent  circumstances,  not  a  pauper,  becomes  insane,  ap- 
plication may  be  made  in  his  behalf  to  any  county  judge,  special  county  judge,  judge  of 
a  superior  court  or  common  pleas,  of  the  county  where  he  resides,  and  said  judge  shall 
fully  investigate  the  facts  of  the  case,  both  as  to  the  question  of  his  indigence  as  well 
as  to  that  of  his  insanity.  And  if  the  judge  certifies  that  satisfactory  proof  of  his  insanity 
has  been  adduced,  and  that  such  person  has  become  insane  within  one  year  next  prior 
to  the  granting  of  the  order  of  admission,  and  that  his  estate  is  insufficient  to  support 
him  and  his  family  (or,  if  he  has  no  family,  himself),  while  under  the  visitation  of  insanity, 
then  it  shall  be  the  duty  of  any  judge,  before  whom  an  application  for  that  purpose  is 
made,  to  cause  reasonable  notice  thereof,  and  of  the  time  and  place  of  hearing  the  same, 
to  be  given  to  one  of  the  superintendents  of  the  poor  of  the  county  chargeable  with  the 
expense  of  supporting  such  person  in  a  State  asylum,  if  admitted,  and  he  shall  then  pro- 
ceed to  ascertain  when  such  person  became  insane,  and  shall  state  in  his  certificate  that 
satisfactory  proof  has  been  adduced  before  him  that  such  person  became  insane  within  a 
year  next  prior  to  the  date  of  such  certificate.  On  granting  such  certificate  the  judge 
may,  in  his  discretion,  require  the  friends  of  the  patient  to  give  security  to  the  superin- 
tendent of  the  poor  of  the  county  to  remove  the  patient  from  the  asylum  at  the  end  of 
the  two  years,  in  case  he  does  not  sooner  recover.  When  a  patient  who  is  admitted 
into  an  asylum  on  the  certificate  of  any  judge,  given  as  hereinbefore  recited,  has  remained 
in  such  asylum  two  years,  and  has  not  recovered,  the  superintendent  of  the  asylum  shall 
send  a  written  notice  to  the  county  judge  of  the  county  from  which  he  was  sent,  that  such 
patient  has  remained  in  the  asylum  two  years,  and  has  not  recovered,  and  that,  in  case 
he  is  not  removed  therefrom,  the  expense  of  his  support  will  be  chargeable  to  the  county 
until  he  is  so  removed,  and  such  expense  shall  be  chargeable  to  the  county  accordingly. 
But  in  every  case  where  a  patient,  admitted  into  an  asylum  as  hereinbefore  provided, 
shall  have  remained  there  two  years,  and  has  not  recovered,  the  managers  of  the  asylum 
may,  in  their  discretion,  cause  such  person  to  be  returned  to  the  county  whence  he  came, 
and  charge  the  expense  of  such  removal  to  the  county.  The  judge  granting  said  order 
of  indigence,  shall  file  all  papers  belonging  to  such  proceedings,  together  with  his  de- 
cision, with  the  clerk  of  the  county,  and  report  the  facts  to  the  supervisors,  whose  duty  it 
shall  be,  at  their  next  annual  meeting,  to  raise  the  money  requisite  to  meet  the  expenses 
of  support  of  such  indigent  lunatic. 

Sec.  15.  When  an  insane  person  in  indigent  circumstances,  not  a  pauper,  shall  have 
been  sent  to  any  State  asylum  by  his  friends,  who  have  paid  his  bills  therein  for  six 
months,  if  the  superintendent  shall  certify  that  he  is  a  fit  patient,  and  likely  to  be  bene- 
fited by  remaining  in  the  institution,  the  supervisors  of  the  county  of  his  residence  are 
authorized  and  required,  upon  an  application  under  oath  in  his  behalf,  to  raise  a  sum  of 
money  sufficient  to  defray  the  expenses  of  his  remaining  there  another  year,  and  to  pay 
the  same  to  the  treasurer  of  the  asylum.  And  they  shall  repeat  the  same  for  one  year 
more,  upon  like  application,  and  the  production  of  a  new  certificate  of  like  import  from 
the  superintendent  of  such  asylum. 

Sec.  16.  The  expense  of  sending  any  lunatic  to  a  State  asylum,  and  of  supporting  him 
there,  shall  be  defrayed  by  the  county  or  town  to  which  he  may  be  chargeable.  If  charge- 


656  APPENDIX   A. 

able  to  a  county,  or  to  any  town  whose  poor-moneys  are  required  to  be  paid  into  the 
county  treasury,  such  expense  shall  be  paid  by  the  county  treasurer  out  of  the  funds  ap- 
propriated for  the  support  of  the  poor  belonging  to  such  county  or  town,  after  being  al- 
lowed and  certified  by  the  county  superintendents.  If  such  lunatic  be  chargeable  to  a 
town  whose  poor-moneys  are  not  required  to  be  paid  into  the  county  treasury,  such  ex- 
pense shall  be  paid  by  the  overseers  of  the  poor  thereof. 

Sec.  17.  The  overseers  of  the  poor  of  any  city  or  town  shall  have  the  same  remedies 
to  compel  the  committee  or  guardian  of  the  estate  of  any  lunatic  to  confine  and  main- 
tain such  lunatic,  and  to  collect  of  such  committee  the  cost  and  charges  of  his  confine- 
ment and  support,  as  are  given  in  the  preceding  sections  against  the  relatives  of  such 
lunatic.  And  the  court  of  general  sessions  of  the  peace  of  the  city  or  county  shall  make 
orders  against  such  committee  personally,  and  enforce  them  in  the  same  manner  as  against 
the  relatives  of  any  poor  person,  so  long  as  such  committee  has  any  property  in  his  hands, 
for  the  support  of  such  lunatic. 

Sec.  18.  None  of  the  foregoing  provisions  shall  be  deemed  to  restrain  or  abridge  the 
power  and  authority  of  the  supreme  court,  the  superior  court,  and  the  court  of  common 
pleas  of  the  city  and  county  of  New  York,  or  the  superior  court  of  the  city  of  Buffalo, 
or  the  city  court  of  Brooklyn,  or  any  county  courts,  concerning  the  safe  keeping  of  any 
lunatics,  or  the  charge  of  their  persons  or  estates. 

Sec.  19.  The  county  superintendents  of  the  poor  shall  have  all  the  powers  and 
authority  herein  given  to  overseers  of  the  poor  of  any  town. 

Form  of  Medical  Certificate. 
State  of  New  York,  \ 

County  of .  J  ^^' 

I, ,  a  resident  of ,  in  the  county  aforesaid,  being  a  graduate 

of  ,  and  having  practiced  as  a  physician,  hereby  certify,  under  oath,  that  on  the 

day  of ,  I  personally  examined ,  of ,  [here  insert  sex,  age, 

married  or  single,  and  occupation,]  and  that  the  said is  insane,  and  a  proper 

person  for  care  and  treatment,  under  the  provisions  of  chapter  446  of  the  Laws  of  1874. 

I  further  certify  that  I  have  formed  this  opinion  upon  the  following  grounds,  viz. : 
[here  insert  facts  upon  which  such  opinion  rests.] 

And  I  further  declare  that  my  qualifications  as  a  medical  examiner  in  lunacy  have  been 
duly  attested  and  certified  by  [here  insert  the  name  of  the  judge  granting  such  certifi- 
cate.] 

Sworn  to  and  subscribed  before  l 
me  this day  of ,  188  .  j 


Judge's  Certificate  of  Qualification. 
Iss. 


State  of  New  York, 

County  of  . 

I  hereby  certify  that ,  of  ,  is  personally  known  to  me  as  a 

reputable  physician,  and  is  possessed  of  the  qualifications  required  by  chapter  446  of  the 
Laws  of  1874. 

Licenses  for  Private  Asylums. 
Laws  0/18^4,  Chapter  44.J,  Title  Ninth. 

Section  i.  No  person  or  association  shall  establish  or  keep  an  asylum,  institution, 
house  or  retreat  for  the  care,  custody,  or  treatment  of  the  insane  or  persons  of  unsound 
mind,  for  compensation  or  hire,  without  first  obtaining  a  license  therefor  from  the  State 
commissioner  in  lunacy,  provided  that  this  section  shall  not  apply  to  any  State  asylum 
or  institution,  or  any  asylum  or  institution  established  or  conducted  by  any  county;  and 
provided,  also,  that  it  shall  not  apply  to  cases  where  an  insane  person  or  person  of  un- 
sound mind  is  detained  and  treated  at  his  own  house  or  that  of  some  relative. 

Sec.  2.  Every  application  for  such  license  shall  be  accompanied  by  a  plan  of  the  prem- 
ises proposed  to  be  occupied,  describing  the  capacities  of  the  buildings  for  the  uses  in- 
tended, the  extent  and  location  of  grounds  appurtenant  thereto,  and  the  number  of  pa- 
tients of  either  sex  proposed  to  be  received  therein  ;  and  it  shall  not  be  lawful  for  said 
commissioner  to  grant  any  such  license  without  having  first  visited  the  premises  proposed 
to  be  licensed,  and  being  satisfied  by  such  examination  that  they  are  as  described,  and  are 
otherwise  fit  and  suitable  for  the  purposes  for  which  they  are  designed  to  be  used. 


ABSTRACT    OF    LAWS    RELATING    TO    THE    INSANE.  65/ 

State  Commissioner  in  Lunacy. 
Laws  of  i8y4,  Chapter  44J. —  Title  Tenth,  as  amended  by  Lazvs  of  i8y6,  Chapter  267. 

Section  i.  The  governor  shall  nominate,  and  by  and  with  the  advice  and  C(;nsent  of 
the  Senate,  appoint  an  experienced  and  competent  physician,  who  shall  be  designated  as 
the  State  commissioner  in  lunacy,  who  shall  hold  his  office  for  five  years  and  receive  an 
annual  salary  of  four  thousand  dollars,  and  travelling  and  other  incidental  expenses  not 
to  exceed  one  thousand  dollars,  and  a  sum  not  to  exceed  two  hundred  dollars  to  pay  office 
rent  and  fuel,  to  be  paid  on  presentation  of  vouchers  to  the  comptroller. 

Sec.  2.  It  shall  be  the  duty  of  such  commissioner  to  examine  into  and  report  annually 
to  the  legislature  on  or  before  the  fifth  day  of  January,  the  condition  of  the  insane  and 
idiotic  in  this  State  and  the  management  and  conduct  of  the  asylums,  public  and  private, 
and  other  institutions  for  their  care  and  treatment.  The  duties  of  said  commissioner  in 
regard  to  the  insane  shall  be  performed  so  as  not  to  prejudice  the  established  and  reason- 
able regulations  of  such  asylums  and  institutions  aforesaid  ;  and  it  shall  be  the  duty  of 
the  ofiicers  and  others  respectively  m  charge  thereof,  to  give  such  commissioner,  at  all 
times,  free  access  to  and  full  information  concerning  the  insane,  and  their  treatment  therein. 
It  shall  also  be  the  duty  of  such  commissioner  to  inquire  and  report,  from  time  to  time, 
as  far  as  he  may  be  able,  the  results  of  ihe  treatment  of  the  insane  of  other  States  and 
countries,  together  with  such  particulars  pertaining  thereto  as  he  may  deem  proper. 

Sec.  3.  The  said  commissioner  shall  have  power  to  make  and  use  an  official  seal,  and 
all  copies  of  papers  and  documents  in  his  possession  and  custody  may  be  authenticated  in 
the  usual  form  under  his  official  seal  and  signature,  and  used  as  evidence  in  all  courts 
and  places  in  this  State,  in  like  manner  as  similar  certificates  emanating  from  any  other 
public  officer. 

Sec.  4.  The  said  commissioner  is  hereby  empowered  to  issue  compulsory  process  for 
the  attendance  of  witnesses  and  production  of  papers,  to  adm.inister  oaths,  and  to  ex- 
amine persons  under  oath,  and  to  exercise  the  same  powers  as  belong  to  referees  ap- 
pointed by  the  supreme  court,  in  all  cases  where,  from  evidence  laid  before  him,  there 
is  reason  to  believe  that  any  person  is  wrongfully  deprived  of  his  liberty,  or  is  cruelly, 
negligently  or  improperly  treated  in  any  asylum,  institution  or  establishment,  public  or 
private,  for  the  custody  of  the  insane;  or  whenever  there  is  inadequate  provision  made 
for  their  skilful  medical  care,  proper  supervision  and  safe  keeping  ;  and  if  the  same  shall 
be  proved  to  his  satisfaction,  he  is  further  empowered  to  issue  an  order  in  the  name 
of  the  people  of  the  State  and  under  his  official  hand  and  seal,  directed  to  the  superin- 
tendent or  managers  of  such  institution,  requiring  them  to  modify  such  treatment  or  ap- 
ply such  remedies,  or  both,  as  shall  therein  be  specified.  And  in  case  such  order  is  dis- 
obeyed, or  negligently  executed,  the  commissioner  may,  and  it  shall  be  his  duty  to  pre- 
sent such  order,  with  a  statement  of  the  facts  duly  verified  upon  which  it  was  made,  to  a 
justice  of  the  supreme  court,  who  may  thereupon,  by  order,  require  such  superintendent 
or  manager  to  show  cause  before  such  or  some  other  justice  of  the  supreme  court  at  a 
place  in  the  judicial  district  where  such  asylum,  institution  or  establishment  is  situated, 
and  at  a  time  specified  in  such  order,  not  less  than  two  days  after  the  service  thereof, 
why  an  order  should  not  be  made  dn-ecting  performance  of  such  order  of  the  commis- 
sioner, and  on  failure  to  so  show  cause,  the  said  justice  shall  make  such  order,  and,  for  any 
disobedience  of  any  order  made  pursuant  to  the  provisions  of  this  section,  the  same  pro- 
ceedings may  be  taken  to  compel  performance  thereof,  or  to  punish  for  contempt  for 
such  disobedience,  as  may  be  had  for  such  purposes  in  civil  actions. 

General  Statutes,  i8y8,  Chapter  ^7. 

Section  i.  The  State  commissioner  in  lunacy  is  hereby  empowered  to  ernploy  a  steno- 
grapher, whenever  any  testimony  is  to  be  taken  before  him  in  the  discharge  of  his  official 
duties,  and  the  charges  of  such  stenographer  shall  be  paid  by  the  comptroller  upon  pre- 
sentation of  vouchers  duly  attested  :  Provided,  such  charges  shall  not  exceed  ten  dollars 
per  day  for  the  time  actually  employed,  nor  one  thousand  dollars  in  any  one  year  in  the 
aggregate. 

Sec.  2.  Whenever  the  said  commissioner  shall  undertake  any  investigation  into  the 
general  management  and  administration  of  any  asylum,  institution  or  establishment,  pub- 
lic or  private,  for  the  custody  of  the  insane,  he  shall  give  notice  thereof  to  the  district- 
attorney  of  the  county  in  which  such  asylum  or  institution  is  situated,  and  it  shall, 
thereupon,  be  the  duty  of  such  district-attorney  to  appear  at  such  investigation  in  behalf 
of  the  people,  and  to  examine  all  witnesses  who  may  be  in  attendance  thereat. 

42 


658 


APPENDIX    A, 


Committees  for  the  Insane. 
See  the  N'e-cu  York  Code  of  Civil  Procedure. —  Title    VI. 

Proceedings  for  the  appointment  of  a  committee  of  the  person  and  of  the  property  of 
a  lunatic,  idioi  or  habitual  drunkard;  general  powers  and  duties  of  the  committee. — Sees. 
2320-2344.  _     . 

The  provisions  of  this  title  are  founded  mainly  upon  Laws,  1874,  chap.  446,  but  are 
extended  to  habitual  drunkards. 

Disposition  of  the  Real  Property  of  the  Insane. 

See  the  A'e-u)  York  Code  of  Civil  Procedure. —  Title  VII. 

Proceedings  for  the  disposition  of  the  real  property  of  an  infant,  lunatic,  idiot,  or 
habitual  drunkard. — Sees.  2344-2364. 


NORTH  CAROLINA. 

[See  Laws  of  North  Carolina  1881,  chap.  133;  chap.  206;  chap.  297.] 

For  admission  to  asylum,  some  respectable  citizen  residing  in  the  county  of  the  alleged 
insane  person  shall  make  and  file  with  the  justice  of  the  peace  of  the  county,  an  affidavit, 
stating  that  he  has  carefully  examined  the  alleged  lunatic  and  believes  him  to  be  insane 
and  a  tit  subject  for  admission  to  the  asylum. 

Such  alleged  lunatic  is  then  brought  before  the  justice,  who  shall  associate  with  him- 
self two  or  more  justices  of  the  county,  who,  together,  shall  proceed  to  examine  into 
the  condition  of  such  person,  and  shall  take  the  testimony  of  at  least  one  respectable  phy- 
sician. 

If  any  two  of  the  justices  decide  that  such  person  is  insane,  and  some  friend  will  not 
give  security  to  take  proper  care  of  him,  then  the  justices  shall  cause  such  person  to  be 
removed  to  an  asylum. 

The  board  of  directors  of  the  asylum  have  discretion  to  determine  who  are  proper 
persons  to  receive. 

If  a  person  found  to  be  insane  has  sufficient  property  and  expresses  a  wish  to  be  placed 
in  some  asylum  outside  of  the  State,  and  the  justices  and  physicians  who  have  examined 
such  person  deem  it  proper,  he  may  be  sent  to  the  asylum  so  chosen  as  a  patient. 

It  is  the  duty  of  any  person  having  the  legal  custody  of  the  estate  of  such  lunatic  to 
supply  the  funds  for  his  or  her  support  in  such  asylum  if  they  are  sufficient  for  that  pur- 
pose, over  and  beyond  maintaining  those  who  may  be  legally  dependent  on  said  estate. 


OHIO. 

[See  Revised  Statutes  of  Ohio  (1S80),  sees.  698-751,  6302-6316,  7242.  Laws  of  1881, 
pp.  62  and  I02;   Laws  of  1S83,  p.  103.] 

Each  State  Asylum  is  under  the  charge  of  a  board  of  trustees. 

For  the  admission  of  patients  to  any  of  the  asylums  for  the  insane  the  following  pro- 
ceedings shall  be  had ;  some  resident  citizen  of  the  proper  county  shall  file  with  the  pro- 
bate judge  of  such  county,  an  affidavit,  substantially  as  follows  : 

State    of  Ohio, 


County ■ 


\ss. 


the  undersigned,  a  citizen  of County,  Ohio,  being  sworn, 

says  that  he  believes is  insane  (or  that  in  consequence  of  his  insanity  his 

being  at   large  is  dangerous  to  the  community).     He  has  a  legal  settlement  in 

township,  m  this  county. 

Dated  this  —  day  of ,  A.D. .  . 

When  the  affidavit  is  filed  the  judge  shall  cause  the  person  alleged  to  be  insane  to  be 
brought  before  him,  and  witnesses,  including  one  physician,  to  be  summoned.     If  any 


ABSTRACT   OF   LAWS    RELATING   TO    THE    INSANE.  659 

person  disputes  the  alleged  insanity,  such  witnesses  shall  be  subpoenaed  as  are  demanded 
on  behalf  of  the  person  allegtd  to  be  insane.  If  by  reason  of  the  condition  of  the  alleged 
insane  person,  it  is  deemed  improper  to  bring  him  into  the  probate  court,  the  judge 
shall  personally  visit  such  person  and  certify  that  he  has  ascertained  the  condition  of  such 
person  by  actual  inspection. 

If  after  hearing  the  testimony  the  judge  is  satisfied  that  the  person  is  insane,  he  shall 
cause  a  certificate  to  be  made  by  the  medical  witness  in  attendance,  which  shall  set. 
forth  full  details  concerning  the  patient  as  specifically  provided  by  the  statute,  and 
the  judge  may  then  issue  a  warrant  of  commitment  to  the  asylum. 

The  relatives  of  any  person  charged  with  insanity  or  found  to  be  insane,  shall  in  all 
cases  have  the  right  to  take  charge  of  and  keep  such  insane  person  charged  with  insanity 
if  they  desire  so  to  do,  and  in  such  case  the  probate  judge  before  whom  the  inquest  has 
been  held,  shall  deliver  such  insane  person  to  them. 

For  Admission  of  Inmates  into  Longview  Asylum. 

Some  resident  citizen  of  Hamilton  County  must  file  with  the  probate  judge  thereof,  an 
afi&davit  substantially  as  follows  : 

State  of  Ohio,  1 

Hamilton  County,  j^' 

The  undersigned,  a  citizen  of  Hamilton  County,  Ohio,  being  sworn,  says,  that  he  believes 
to  be  insane,  and  a  fit  subject  for  the   lunatic  asylum  ;  he  is  a  resident  of 


Hamilton  County,  has  a  legal  settlement  in  township.     These  facts  are  known 

by and (naming  at  least  two  persons). — J^ev.  Stats.,  sec. 

738. 

Proceedings  will  then  be  had  substantially  as  given  above. 

The  probate  court,  upon  satisfactory  proof,  will  appoint  a  guardian  for  any  insane 
person,  which  guardian,  by  virtue  of  such  appointment,  shall  be  also  the  guardian  of  the 
minor  children  of  his  ward,  unless  the  court  appoint  some  other  person  as  their  guar- 
dian.— Rev.  Stats.,  sec.  6302.  I 

OREGON. 

[See  Laws  of  Oregon,  1878,  p.  72;  Laws  of  Oregon,  1880,  p.  49.] 

The  county  judge  of  any  county  in  this  State,  upon  application  of  any  two  house- 
holders in  his  county,  in  writing  under  oath,  setting  forth  that  any  person,  by  reason  of 
insanity,  as  the  case  may  be,  is  suffering  from  neglect,  exposure  or  otherwise,  or  is  unsafe 
to  be  at  large,  shall  cause  such  person  or  persons  to  be  brought  before  him  at  such  time 
and  place  as  he  may  direct;  and  said  county  judge  shall  also  cause  to  appear  at  the  same 
time  and  place,  two  or  more  competent  physicians  and  the  prosecuting  attorney  of  his 
judicial  district  or  his  deputy,  or  (in  the  event  of  his  absence  or  inability  to  attend)  some 
practicing  attorney  of  the  State,  whose  duty  it  shall  be  to  represent  the  State  and  protect 
its  interests,  who  shall  proceed  to  examine  the  person  or  persons  alleged  to  be  insane  or 
idiotic,  and  if  the  said  physicians  shall  certify  upon  oath,  that  the  said  person  or  persons 
are  insane  or  idiotic,  as  the  case  may  be,  and  the  county  judge  shall  find,  from  the  con- 
sideration of  the  said  certificate  and  the  testimony  that  may  be  produced  before  him,  that 
the  said  person  or  persons  are  insane  or  idiotic,  then  said  judge  shall  cause  the  said  in- 
sane or  idiotic  person  or  persons  to  be  conveyed  to  and  placed  in  charge  of  the  parties 
contracting  to  keep  and  care  for  the  insane  and  idiotic  of  this  State  :  Provided,  that  an  ap- 
peal shall  lie  from  the  decision  of  the  said  county  judge  in  such  cases,  in  the  same  manner 
as  is  provided  for  appeal  from  the  judgments  of  county  courts  in  other  cases,  which  appeal 
may  be  taken  either  by  the  householders  making  such  application,  or  by  or  on  behalf  of 
any  person  who  shall  be  adjudged  to  be  insane  or  idiotic  ;  or  the  same  may  be  taken  by 
the  State  whenever,  in  the  judgment  of  the  prosecuting  attorney  for  the  district,  the  in- 
terest of  the  State  requires  such  appeal  to  be  taken  :  Provided  further,  that  the  county 
judge  shall  make  diligent  inquiries,  and  when  any  insane  or  idiotic  person  committed 
under  this  act,  shall  be  found  to  own  any  estate,  real  or  personal,  said  judge  shall  im- 
mediately, without  further  petition  or  notice,  appoint  a  guardian  for  the  estate  of  such 
person,  who  shall  execute  his  trust  under  the  direction  of  said  court,  make  the  same  re- 


66o  APPENDIX   A. 

turns  and  give  the  same  security  as  in  case  of  the  estate  of  a  minor,  and  such  estate  shall 
be  liable  to  the  county  for  the  cost  of  such  commitment,  and  to  the  State  for  the  costs  of 
conveying  such  insane  or  idiotic  person  to  the  asylum. — Lazvs  of  1878,  p.  72. 

The  governor,  secretary  of  state  and  State  treasurer  were,  in  1880,  designated  as 
commissioners  for  the  purpose  of  erecting  a  suitable  State  Insane  Asylum. — See  Laws, 
1880,  p.  49. 

PENNSYLVANIA. 

[See  Laws  of  1S69,  No.  54,  and  "An  act  relative  to  the  supervision  and  control  of 
hospitals  or  houses  in  which  the  insane  are  placed  for  treatment  or  detention."  Approved 
the  8th  day  of  May,  1883.] 

Sections  1-6,  inclusive,  refer  to  the  appointing  and  managing  of  the  members  of  the 
State  Board  of  Charities,  and  their  Committee  on  Lunacy,  their  duties,  etc. 

Sec.  7.  The  board  shall  have  power  from  time  to  time,  with  the  consent  of  the  chief 
justice  of  the  supreme  court  and  of  the  attorney-general,  to  ordain  rules  and  regulations 
on  the  following  matters,  so  far  as  the  same  are  not  inconsistent  with  any  laws  of  this 
Commonwealth  then  in  force  and  of  any  provisions  of  this  act. 

(l.)  The  licensing  of  all  houses  or  places  in  which  any  person  can  be  lawfully  detained 
as  a  lunatic  or  of  unsound  mind,  upon  compensation  paid  to  or  received  by  the  owner  or 
occupant  of  such  house  or  place  directly  or  indirectly  for  the  care  of  such  lunatic,  and 
also  of  all  houses  or  places  in  which  more  than  one  person  of  unsound  mind  is  detained 
or  resides  :  Provided,  That  this  clause  shall  not  extend  to  any  gaol  or  prison ;  and  pro- 
vided also,  That  the  board,  with  consent  as  aforesaid,  may  from  time  to  time  exempt  any 
particular  hospital  established  by  the  State  or  under  any  municipal  authority,  or  any 
eleemosynary  institution,  from  the  obligation  to  apply  for  or  obtain  a  license ;  and  no 
such  institution  now  existing  shall  be  required  to  take  out  a  license  until  required  to  do 
so  by  the  board  with  the  consent  aforesaid. 

(2.)  Regulations  to  insure  the  proper  treatment  of  persons  detained  in  anv  house  or 
place,  whether  licensed  or  not,  that  are  subject  to  the  provisions  of  this  act,  and  to  guard 
against  improper  or  unnecessary  detention  of  such  persons. 

(3.)  Regulations  of  the  forms  to  be  observed  warranting  the  commitment,  transfer  of 
custody,  and  discharge  of  all  lunatics  other  than  those  committed  by  order  of  a  court  of 
record,  and  as  to  these,  with  the  consent  of  the  presiding  judge  of  the  court  under  whose 
order  the  person  is  detained. 

(4.)  The  visitation  of  all  houses  or  places  licensed  under  this  act,  or  in  which  any 
persons  are  detained  as  lunatics,  and  of  all  persons  detained  therein. 

(5.)  The  withdrawal  of  such  licenses,  and  the  imposition  of  conditions  under  which 
they  shall  continue. 

(6.)  Reports  and  information  to  be  furnished  by  the  manager  or  managers  of  all  houses 
or  places,  subject  to  the  provisions  of  this  act  and  by  the  boards  of  visitors. 

(7.)  Reguladons  as  to  the  number  of  persons  that  may  be  detained  and  the  accommo- 
dations to  be  provided,  and  food,  clothing,  fuel  to  be  furnished  in  any  house  or  building 
subject  to  the  provisions  of  this  act,  the  manner  of  such  detention  and  the  restraints 
imposed,  the  means  of  communication  by  those  detained  with  the  relatives,  friends,  and 
other  persons  outside  the  houses  and  places  of  detention. 

Sec.  8.  There  shall  be  appointed  boards  of  visitors  of  all  houses  or  places  licensed 
under  or  subject  to  the  provisions  of  this  act,  or  in  which  any  person  of  unsound  mind 
is  detained,  and  for  the  care  or  custody  of  whom  compensation  of  any  kind  is  received, 
or  where  more  than  one  such  person  is  detained.  One  such  board  shall  be  appointed  in 
every  county  in  which  there  is  a  house  or  place  subject  to  the  provisions  of  this  act,  of 
not  less  than  three  persons,  and  in  each  county,  where  there  are  more  than  one  such 
house  or  place,  the  number  constituting  the  board  of  visitors  of  such  county  shall  be 
increased  in  the  discretion  of  the  committee  on  lunacy. 

Sec.  9.  The  members  of  the  board  of  visitors  shall  be  appointed  by  the  board  in  each 
year,  and  shall  continue  until  their  successors  are  appointed,  and  the  board  may  remove 
the  visitors  and  fill  vacancies  in  the  office. 

Sec.  10.  Women  may  be  appointed  members  of  the  board  of  visitors,  and  at  least  once 
a  year  these  boards  shall  be  filled  up  so  that  members  who  have  failed  to  act  shall  be 
removed. 


ABSTRACT  OF  LAWS  RELATING  TO  THE  INSANE.        66l 

Sec.  II.  It  shall  not  be  lawful  for  any  person  or  persons,  or  corporation,  not  excepted 
from  the  obligation,  to  obtain  a  license  under  this  act  to  keep  or  maintain  a  house  or 
place  for  the  reception  or  custody  of  persons  of  unsound  mind  without  having  received  a 
license  under  this  act,  nor  when  such  license  has  expired  or  been  withdrawn,  or  sus- 
pended ;  and  the  manager  and  occupant  of  any  such  house,  within  which  more  than 
one  person  shall  be  detained  as  being  a  person  of  unsound  mind,  for  compensation  re- 
ceived, and  the  manager  and  occupant  of  any  such  house  or  place,  wherein  more  than, 
one  person  is  received  and  detained,  with  or  without  compensation,  and  while  there  is 
no  license  in  force  authorizing  the  keeping  of  such  house  or  place,  shall  be  deemed  guilty 
of  a  misdemeanor. 

Sec.  12.  Any  person  having  charge  or  control  of  any  house  or  place  subject  to  the 
provisions  of  this  act,  used  for  the  detention,  care,  or  custody  of  a  lunatic,  who  shall 
violate  or  omit  to  observe  any  regulation  of  the  committee  on  lunacy  authorized  by  this 
act,  after  a  copy  of  the  same  has  been  left  at  the  said  house  or  place,  or  delivered  to  the 
person  named  in  the  license,  or  to  the  manager  of  such  house,  shall  be  deemed  guilty  of 
a  misdemeanor,  and  all  common-law  rights  of  action  or  indictments  are  also  reserved. 

Sec.  13.  The  Board  of  Public  Charities  shall  from  time  to  time  provide  for  an  effectual 
visitation  of  all  persons  confined  as  insane  in  all  places  over  which  they  are  given  juris- 
diction by  this  act,  and  an  inspection  of  such  houses  or  places  of  confinement  and  of  the 
mode  of  treatment  of  the  insane. 

Sec.  14.  The  board  shall  make  rules  to  insure  to  the  patients  the  admission  of  all 
proper  visitors,  being  members  of  their  family,  or  personal  friends,  agents,  or  attorneys, 
and  compel  obedience  to  such  regulations. 

Sec.  15.  The  detention  of  any  person  as  insane  in  any  house  or  place  made  subject  to 
the  provisions  of  this  act,  without  compliance  with  the  requisitions  of  this  act,  shall  be  a 
misdemeanor  on  the  part  of  any  person  concerned  in  such  detention,  who  has  omitted  or 
permitted  the  omission  of  any  of  the  requirements,  and  the  party  aggrieved  shall  also  be 
entiiled  to  his  action  for  damages. 

Sec.  16.  No  verdict  or  judgment  shall  be  entered  in  any  action,  nor  shall  any  judg- 
ment be  entered  on  any  indictment  for  such  detention  as  against  any  person  or  persons 
who  are  subject  to  the  regulations  and  provisions  of  this  act,  who  shall  have  complied 
with  the  requirements  of  this  act,  unless  the  judge,  after  trial  and  verdict,  shall  certify 
that  there  was  proof  to  his  satisfaction  that  the  party  charged  acted  with  gross  negligence 
or  corruptly,  or  that  he  acted  without  reasonable  or  probable  cause,  or  was  actuated  by 
motives  other  than  the  good  of  the  person  restrained. 

Sec.  17.  In  all  buildings  or  establishments  where  an  insane  person  is  detained,  which 
are  subject  to  the  provisions  of  this  act,  there  shall  be  kept  the  following  books,  which 
shall  be  at  all  times  open  to  the  inspection  of  any  member  of  the  committee  on  lunacy, 
or  the  board  of  visitors  of  the  proper  county. 
An  Admission  Book. 
A  Discharge  Book. 

A  Case  Book,  in  which  there  shall  be  regularly  entered  all  the  facts  bearing  on  each 
patient  and  his  case. 

A  Medical  Journal,  in  which  there  shall  be  at  least  once  a  week  .a  statement  written  of 
all  matters  which  are  of  special  importance  bearing  on  the  treatment  and  condition  of 
the  patients. 

Sec.  18.  No  person  shall  be  received  as  a  patient  for  treatment  or  for  detention  into 
any  house  or  place  where  more  than  one  insane  person  is  detained,  or  into  any  house  or 
place  where  one  or  more  insane  persons  are  detained,  for  compensation,  without  a  cer- 
tificate signed  by  at  least  two  physicians,  resident  in  this  Commonwealth,  who  have  been 
actually  in  the  practice  of  medicine  for  at  least  five  years,  both  of  whom  shall  certify  that 
they  have  examined  separately  the  person  alleged  to  be  insane,  and,  after  such  an  ex- 
amination had,  do  verily  believe  that  the  person  is  insane,  and  that  the  disease  is  of  a 
character  which,  in  their  opinion,  requires  that  the  person  should  be  placed  in  a  hospital 
or  other  establishment  where  the  insane  are  received  for  care  and  treatment,  and  that 
they  are  not  nearly  related  by  blood  or  marriage  to  the  person  alleged  to  be  insane,  nor 
in  any  way  connected  as  a  medical  attendant  or  otherwise  with  the  hospital  or  other 
establishment  in  which  it  is  proposed  to  place  such  person. 

Sec.  19.  The  certificate  above  provided  for  shall  have  been  made  within  one  week  of 
the  examination  of  the  patient  and  within  two  weeks  of  the  time  of  the  admission  of  the 
patient,  and  shall  be  duly  sworn  to  or  affirmed  before  a  judge  or  magistrate  of  this  com- 
monwealth, and  of  the  county  where  such  person  has  been  examined,  who  shall  certify 
to  the  genuineness  of  the  signatures  and  to  the  standing  and  good  repute  of  the  signers. 


662  APPENDIX    A. 

And  any  person  falsely  certifying  as  aforesaid  shall  be  guilty  of  a  misdemeanor  and  also 
liable  civilly  to  the  party  aggrieved. 

Sec.  20.  No  person  alleged  to  be  insane  shall  be  received  into  any  house  for  treatment 
or  for  detention  unless  at  the  time  of  such  reception  the  person  or  persons  at  whose  instance 
the  person  is  received  shall^  by  a  writing  signed,  state  that  the  person  has  been  removed 
and  is  to  be  detained  at  his  or  her  request  under  the  belief  that  such  detention  is  neces- 
sary and  for  the  benefit  of  the  insane  person. 

Sec.  21.  There  shall  also  be  delivered  to  the  person  or  persons  having  supervision  or 
charge  of  the  house  a  written  statement  of  the  following  facts  relative  to  the  person  to 
be  detained,  signed  by  the  person  or  persons  at  whose  instance  the  insane  person  has 
been  removed  and  detained,  or  if  the  facts  be  not  known  it  shall  be  so  stated:  i.  The 
name.  2.  Age.  3.  Residence  for  the  past  year,  or  for  so  much  thereof  as  is  known. 
4.  Occupation,  trade  or  employment.  5.  Parents,  if  living.  6.  Husband  or  wife.  7. 
Children.  8.  Brothers  and  sisters,  and  the  residence  of  each  of  these  persons.  9.  If 
not  more  than  one  of  these  classes  is  known,  the  names  and  residence  of  such  of  the 
next  degree  of  relatives  as  are  known.  10.  A  statement  of  the  time  at  which  the  in- 
sanity has  been  supposed  to  e.\ist,  and  the  circumstances  that  induce  the  belief  that  in- 
sanity exists.  II.  Name  and  address  of  all  medical  attendants  of  the  patient  during  the 
past  two  years. 

Sec.  22.  Should  the  person  in  charge  of  the  house  have  reason  to  believe  that  any  of 
these  statements  have  been  omitted  through  ignorance,  and  that  the  answers  will  be  imme- 
diately furnished,  and  no  reason  existing  to  doubt  the  good  faith  of  the  parties,  after  inquir- 
ing of  the  person  intended  to  be  detained,  it  shall  be  lawful  to  detain  tlie  person  alleged 
to  be  insane  for  such  furtlier  period  as  shall  be  necessary  to  obtain  the  said  statements 
complete,  but  not  exceeding  seven  days. 

Sec.  23.  Within  twenty-four  hours  after  any  person  is  received  into  any  house  for  deten- 
tion as  an  insane  person,  the  person  in  charge  there  shall  enter  or  have  entered  in  a  book 
kept  for  that  purpose,  all  the  facts  stated  in  the  certificate  or  documents  required  to  be  ex- 
hibited at  the  time  of  receiving  the  patient,  and  shall  file  the  originals  and  preserve  them. 
The  regular  medical  attendant  of  the  house  shall,  within  twenty-four  hours  after  the  re- 
ception of  any  patient,  examine  such  patient  and  reduce  to  writing  the  results  of  such 
examination,  and  enter  the  same  upon  a  book  to  be  kept  for  that  purpose,  together  with 
the  opinion  formed  from  such  examination  and  from  the  documents  received  with  the 
patient. 

Sec.  24.  In  case  the  said  medical  attendant  is  of  the  opinion  that  the  detention  is  not 
necessary  for  the  benefit  of  the  patient,  he  shall  notify  the  person  or  persons  at  whose  instance 
the  patient  is  detained,  and  unless  such  person  shall  without  a  delay  not  exceeding  seven 
days  exhibit  satisfactory  proof  of  such  necessity,  the  patient  shall  be  discharged  from  the 
house  and  restored  to  his  family  or  friends. 

Sec.  25.  At  the  time  of  such  examination  the  medical  attendant  shall  himself  cause  the 
patient  distinctly  to  understand,  if  he  or  she  is  capable  of  doing  so,  that  if  he  or  she  desires 
to  see  or  otherwise  communicate  with  any  person  or  persons,  means  will  be  provided  for 
such  interview  or  communication,  and  said  attendant  shall  personally  see  that  proper 
means  are  taken  to  communicate  this  fact  to  the  person  or  persons  indicated  by  the  patient, 
and  any  proper  person  or  persons  not  exceeding  two  shall  be  permitted  to  have  a  full  and 
unrestrained  interview  with  the  patient. 

Sec.  26.  The  statements  furnished  at  the  time  of  the  reception  of  the  patient,  and  at 
the  examination  of  the  patient  by  the  medical  attendant  of  the  house,  shall  be  forwarded 
by  mail  to  the  address  of  the  committee  on  lunacy  within  seven  days  from  the  time  of  the 
reception  of  the  patient,  which  shall  by  them  be  entered  in  a  book,  wdiich  they  shall  keep 
for  this  purpose,  and  at  least  once  in  six  months  there  shall  be  a  report  made  by  tlie 
medical  attendant  of  the  house  on  the  condition  of  each  patient,  together  with  such  other 
matters  relative  to  the  case  as  the  said  committee  may  require,  and  at  any  time  such  re- 
port shall  be  made  upon  the  request  of  the  committee  on  lunacy. 

Sec.  27.  During  the  detention  of  any  person  as  insane  any  medical  practitioner  desig- 
nated by  him  or  by  any  member  of  his  family  or  "  near  friend,"  with  the  sanction  of  a 
judge  of  a  court  of  record  of  the  county  in  which  such  insane  person  resided  at  the  time 
of  his  removal  and  detention,  shall  be  permitted  at  all  reasonable  hours  to  visit  and  ex- 
amine the  patient,  and  such  medical  attendant  shall,  unless  objected  to  by  the  patient,  be 
permitted,  by  request  of  his  or  her  family  or  "  near  friend,"  and  with  the  consent  of  the 
physician  in  chief  of  the  establishment,  to  attend  the  patient  for  all  maladies  other  than 
insanity,  in  the  same  manner  as  if  the  patient  were  in  his  own  home. 

Sec.  28.  All  persons  detained  as  insane  shall  be  furnished  with  materials  and  reason- 


ABSTRACT    OF    LAWS    RELATING   TO    THE    INSANE.  663 

able  opportunity,  in  the  discretion  of  the  superintendent  or  manager,  for  communicating, 
under  seal,  with  any  person  without  the  building,  and  such  communication  shall  be  stamped 
and  mailed.  They  shall  have  the  unrestricted  privilege  of  addressing  communications,  if 
they  so  desire,  not  oftener  than  once  a  month,  to  any  member  of  the  committee  on 
lunacy. 

Sec.  29.  The  provisions  of  this  act  in  respect  of  the  admission  or  discharge  of  patients 
shall  not  extend  to  insane  criminals  in  custody.  Such  persons  shall  not  be  received  ex- 
cept when  delivered  by  a  sheriff  of  tire  county  or  his  deputy,  together  with  an  order  of  the 
court  of  the  county  in  which  he  was  arrested  or  convicted,  having  jurisdiction  of  the  offence, 
under  the  seal  of  the  court,  and  signed  by  a  law  judge,  nor  shall  such  criminals  be  dis- 
charged from  a  hospital  or  other  place  of  detention  for  the  insane  saving  on  a  like  order, 
and  to  the  sheriff  or  his  deputy  producing  such  order,  and  while  detained  as  an  insane 
person,  such  criminal  shall  be  so  kept  as  to  insure  his  detention  until  duly  discharged. 
Whenever  any  person  detained  in  any  gaol  or  prison  is  insane  or  in  such  condition  as  to 
require  treatment  in  a  hospital  for  the  insane,  it  shall  be  the  duty  of  any  law  judge  of  the 
court  under  whose  order  the  person  is  detained,  upon  application,  to  direct  an  inquiry 
into  the  circumstances,  either  by  a  commission  or  otherwise  as  he  shall  deem  proper,  with 
notice  to  the  committee  on  lunacy,  and  if  the  judge  shall  be  satisfied  that  the  person  con- 
fined requires  treatment  in  a  hospital,  he  shall  thereupon  direct  the  removal  of  the  said 
person  from  the  gaol  or  prison  to  a  state  hospital,  which  order  shall  be  executed  by  the 
sheriff  of  the  county  or  his  deputy,  and  the  actual  expenses  of  such  removal  and  the  ex- 
penses of  maintaining  the  person  in  the  hospital  shall  be  paid  by  the  county  liable  for  the 
maintenance  of  the  said  person  in  the  gaol  or  prison  from  which  he  is  removed. 

Sec.  30.  The  trustees,  managers,  and  physician  of  any  hospital,  in  which  a  criminal 
is  confined  by  order  of  any  court,  or  in  which  a  lunatic  has  been  committed  after  an  ac- 
quittal of  crime,  shall  not  discharge,  release,  or  remove  the  prisoner  or  lunatic,  without 
the  order  of  a  court  of  competent  jurisdiction  ;  and  in  case  such  lunatic,  whether  a  con- 
vict or  acquitted,  is  not  set  at  large,  but  is  to  be  removed  to  any  place  of  custody,  other 
than  a  hospital,  the  order  for  removal  shall  not  be  made  without  notice  to  the  committee 
of  lunacy,  and  time  given  them  to  investigate  the  case  and  be  heard  on  the  application. 

Sec.  31.  All  persons  that  have  been  detained  as  insane  (other  than  criminal  insane, 
duly  convicted  and  sentenced  by  a  court)  shall,  as  soon  as  they  are  restored  to  reason, 
and  are  competent  to  act  for  themselves,  in  the  opinion  of  the  medical  attendant  of  the 
house,  be  forthwith  discharged,  and  any  person  so  detained  shall  at  all  times  be  entitled 
to  a  writ  of  habeas  corpus  for  the  determination  of  this  question;  and,  on  the  hearing, 
the  respondent  in  that  writ  shall  be  required  to  pay  the  costs  and  charges  of  the  proceed- 
ing, unless  the  judge  shall  certify  that  there  was  sufficient  ground,  in  his  opinion,  to  war- 
rant the  detention  and  put  the  petitioner  to  his  writ.  In  case  the  discharged  patient  be 
in  indigent  circumstances,  such  person  shall  be  furnished  with  necessary  raiment,  and 
with  funds  sufficient  for  sustenance  and  travel  to  his  home,  to  be  charged  to  the  county 
from  which  such  patient  was  committed. 

Sec.  32.  The  committee  on  lunacy  shall  be  notified  of  all  discharges  within  seven  days 
thereafter,  and  a  record  of  the  same  shall  be  kept  by  the  committee. 

Sec.  33.  The  committee  on  lunacy  may  at  any  lime  order  and  compel  the  discharge  of 
any  person  detained  as  insane  (other  than  a  person  committed,  after  trial  and  conviction 
for  crime,  or  by  order  of  court),  but  such  order  shall  not  be  made,  unless  notice  be  given 
to  the  person  having  charge  of  the  building  in  which  the  patient  is  detained,  and  to  the 
person  orpersons  at  whose  instance  the  patient  is  detained,  and  reasonable  opportunity 
given  them  to  justify  a  further  detention;  and  the  committee  shall  not  sign  an  order  of 
discharge  unless  they  have  personally  attended  and  examined  the  case  of  the  patient. 

Sec.  34.  Persons  voluntarily  placing  themselves  in  any  of  the  houses  provided  for  in 
this  act,  may  be  detained  for  the  time  they  shall  specify  by  an  agreement  signed  by  them 
at  the  time  of  their  admission,  but  not  exceeding  seven  days,  and  they  may  from  time  to 
time  renew  the  authority  to  detain  them  for  a  time  not  exceeding  seven  days  from  such 
renewal.  But  no  agreement  shall  be  deemed  to  authorize  a  detention  unless  signed  in 
the  presence  of  some  adult  person,  attending  as  a  friend  of  the  person  detained,  in  the 
presence  of,  and  also  by  the  person  in  charge  of  the  house,  or  the  medical  attendant. 

Sec.  35.  So  much  of  the  act  entitled  ''  An  act  to  provide  for  the  admission  of  certain 
classes  of  the  insane  into  hospitals  for  the  insane  in  this  Commonwealth,  and  their  dis- 
charge therefrom,"  approved  the  twentieth  day  of  April,  Anno  Domini  one  thousand 
eight  hundred  and  sixty-nine,  number  fifty-four  of  the  Pamphlet  Laws  of  that  year,  as  pro- 
vides "  that  insane  persons  may  be  placed  in  a  hospital  for  the  insane  by  their  legal  guar- 
dians, or  by  their  relatives  or  friends,  in  case  they  have  no  giiardians,  but  never  without 


664  APPENDIX   A. 

the  certificate  of  two  or  more  reputable  physicians,  after  a  personal  examination  made 
within  one  week  of»the  date  thereof,  and  this  certificate  to  be  duly  acknowledged  and 
sworn  to,  or  affirmed,  before  some  magistrate  or  judicial  officer,  who  shall  certify  to  the 
genuineness  of  the  signatures,  and  to  the  respectability  of  the  signers,"  is  amended,  and 
the  persons  thereby  authorized  to  place  an  insane  person  in  a  hospital  are  required  to 
observe  the  forms  and  conditions  required  by  this  act  in  exercising  the  powers  conferred 
by  the  said  act  of  the  twentieth  day  of  April,  Anno  Domini  one  thousand  eight  hundred 
and  sixty-nine,  when  the  insane  person  is  placed  in  any  house,  hospital,  or  place  which 
is  subject  to  the  provisions  of  this  act. 

Sec.  36.  So  much  of  said  act  as  provides  by  section  second,  "  That  it  shall  be  unlaw- 
ful, and  be  deemed  a  misdemeanor  in  law,  punishable  by  a  fine  of  not  exceeding  one 
hundred  dollars,  for  any  superintendent,  officer,  physician,  or  other  employe  of  any  in- 
sane asylum,  to  intercept,  delay,  or  interfere  with,  in  any  manner  whatsoever,  the  trans- 
mission of  any  letter,  or  any  other  written  communication,  addressed  by  an  inmate  of  any 
insane  asylum  to  his  or  her  counsel  residing  in  the  county  in  which  the  home  of  the 
patient  is,  or  in  the  city  or  county  in  which  the  asylum  is  located,"  is  hereby  amended  so 
that  the  same  shall  extend  to  the  superintendents,  officers,  physicians,  servants,  or  other 
employes  of  all  hospitals,  houses,  or  places  which  are  subject  to  the  provisions  of  this  act. 

Sec.  37.  So  much  of  the  said  act  as  provides  by  section  ten,  "  If  the  superintendent 
or  officers  of  any  hospital  for  the  insane  shall  receive  any  person  into  the  hospital,  after 
full  compliance  with  the  provisions  of  this  act,  no  responsibility  shall  be  incurred  by  them 
for  any  detention  in  the  hospital,"  as  applies  to  the  superintendent  or  officers  of  any  hos- 
pital, house,  or  place  made  subject  to  the  provisions  of  this  act,  is  repealed,  and,  in  place 
of  the  provisions  of  that  act  for  the  protection  of  such  superintendents  or  officers,  the  pro- 
visions of  this  act  for  that  purpose  are  substituted. 

Sec.  38.  The  managers  and  officers  of  any  licensed  hospital,  or  licensed  house,  or  place, 
shall  not  be  liable  to  the  penalties  imposed  by  this  act,  and  shall  be  entitled  to  all  the  pro- 
tection of  this  act  in  case  of  receiving  for  detention  a  lunatic,  or  alleged  lunatic,  without 
complying  with  the  requisitions  of  the  act,  if  the  judge  trying  the  cause  shall  certify  that 
the  said  officers  and  managers  had  good  reason  to  believe  that  such  receiving  and  de- 
tention were  necessary  for  the  safety  of  the  lunatic,  or  other  persons,  and  that  the  delay 
required  to  comply  with  the  requirements  of  this  act  would  have  been  injurious  to  the 
person  detained,  or  to  other  persons,  and  that  there  is  no  reason  to  believe  that  they  or 
any  of  them  were  actuated  by  improper  motives.  And  within  forty-eight  hours  after  any 
person  is  thus  received  all  the  requisitions  of  this  act  to  authorize  a  detention  shall  have 
been  complied  with,  or  the  person  discharged  from  custody,  and  the  officers  of  the  hos- 
pital or  place  where  such  lunatic  has  been  thus  received,  shall  forthwith  notify  the 
Board  of  Public  Charities  of  the  facts  connected  with  the  reception  and  detention. 

Sec.  39.  Whenever  any  person  shall  be  found  by  inquisition  to  be  insane,  the  com- 
mittee of  the  person,  or  of  the  estate,  and  also  the  clerk  of  the  court  into  which  the  in- 
quisition has  been  returned,  shall  thereupon  forthwith  send  to  the  committee  on  lunacy 
at  their  principal  office,  a  statement  in  writing,  signed  by  the  committee  of  the  lunatic,  of 
the  name,  age,  sex,  and  residence  of  the  lunatic,  and  the  residence  of  the  committee, 
and  upon  any  change  in  the  residence  or  place  of  detention  of  the  lunatic,  shall  forthwith 
notify  the  committee  of  lunacy  of  such  change.  The  committee  on  lunacy,  or  any  one 
or  more  of  the  members  of  the  committee,  shall  have  power  to  visit  and  examine  the 
said  lunatic,  and  authorize  such  visiting  and  examination  by  their  secretaiy,  or  any  board 
of  visitors,  or  one  or  more  members  thereof,  and  by  a  physician,  and  the  said  committee 
are  authorized  to  apply  to  any  court  having  jurisdiction  over  the  committee,  or  to  a  judge 
of  a  court  of  common  pleas  of  the  county  in  which  the  lunatic  is  a  resident  or  detained, 
to  make  such  orders  for  the  maintenance,  custody,  or  care  of  the  said  lunatic,  and  for 
the  care  and  disposition  of  the  property  of  the  lunatic,  as  the  case  may  require.  From 
any  order,  final  or  otherwise,  thus  made,  an  appeal  may  be  taken  to  the  supreme  court, 
but  such  appeal  shall  not  be  a  supersedeas,  unless  so  ordered  by  the  court  making  the 
order,  or  by  a  judge  of  the  supreme  court,  on  application  and  a  hearing. 

Sec.  40.  This  act  shall  go  into  operation,  etc. 


ABSTRACT    OF    LAWS    RELATING   TO    THE    INSANE.  665 


RHODE  ISLAND. 

[Public  Statutes  of  Rhode  Island,  1882,  title  xii.,  chap.  74.] 

Any  trial  justice  oi-  clerk  of  a  justice  court,  upon  complaint  in  writing,  under  oath, 
that  a  person  within  the  county  is  a  lunatic,  or  is  furiously  mad  and  is  at  large,  shall 
cause  such  person  to  be  apprehended  and  brought  for  examination  before  the  court. 

If  the  court  adjudge  such  complaint  true,  it  shall  commit  such  person  to  a  hospital  or 
asylum  for  the  insane,  unless  a  satisfactory  recognizance  be  given  that  such  person  shall 
not  be  permitted  to  go  at  large. 

Upon  proper  petition  under  oath,  setting  forth  that  any  person  is  insane,  any  justice  of 
the  supreme  court  may  appoint  not  less  than  three  commissioners  to  investigate  and 
report  whether  such  person  should  be  placed  in  a  hospital  or  asylum  for  the  insane. 
Such  commissioners  shall  be  sworn  to  the  faithful  execution  of  their  duties,  shall  give 
notice  to  person  complained  of  as  to  time  and  place  of  hearing  that  he  may  defend  him- 
self by  counsel  or  otherwise,  and  said  commissioners  may  summon  witnesses,  and  shall 
hear  all  evidence  offered  on  either  side. 

The  justice  may  cause  such  person  complained  of  to  be  apprehended  pending  the 
inquisition  of  the  commissioners. 

The  justice  may  confirm  or  disallow  the  report  of  the  commissioners,  and  may  order 
the  person  complained  of  to  be  confined  in  an  asylum,  or  may  dismiss  the  petition  alto- 
gether. 

Any  person  so  committed  to  an  asylum  may  be  discharged  by  an  order  of  any  justice 
of  the  supreme  court,  although  not  restored  to  sanity,  upon  the  written  recommendation 
of  the  trustees  and  superintendent  of  such  institution. 

Insane  persons  may  be  placed  in  State  asylums  by  their  relatives  or  friends,  or,  if 
paupers,  by  the  town  authorities;  but  the  superintendents  of  such  asylums  or  hospitals 
shall  not  receive  any  person  into  custody  without  a  certificate  from  two  practicing  phy- 
sicians of  good  standing  that  such  person  is  insane. 

Upon  the  application  of  a  relative  or  friend,  and  with  the  written  approbation  of  the 
visiting  committee  of  the  trustees,  the  superintendent  of  such  institution  may  discharge 
any  patient  not  committed  by  process  of  law. 

Any  justice  of  the  supreme  court  may,  in  his  discretion,  upon  petition,  setting  forth 
that  a  person  is  improperly  detained  in  an  insane  asylum,  appoint  commissioners  to  in- 
vestigate such  case.  No  notice  is  served  upon  the  person  confined,  and  neither  the 
petitioner  nor  his  counsel  has  the  right  to  visit  or  examine  said  insane  person  except  by 
permission  of  the  superintendent  of  the  asylum,  or  by  special  order  of  the  justice  issuing 
the  commission.  The  personal  examination  by  said  commissioners  must  take  place  at 
the  institution  where  such  person  is  confined,  and,  if  the  commissioners  prefer,  without 
the  presence  of  the  superintendent. 

Such  commissioners  shall  report  to  the  justice,  who  may  either  confirm  or  disallow  the 
same,  and  order  the  discharge  of  the  person  detained,  or  dismiss  the  petition,  in  his 
discretion. 

The  writ  of  habeas  corpus  not  to  be  impaired  or  abridged  by  anything  in  this  chapter. 

Whenever,  on  the  trial  of  any  person  upon  an  indictment,  he  is  acquitted,  on  the 
ground  of  insanity,  the  juiy  shall  so  state,  and  the  court,  if  the  going  at  large  of  such 
person  is  deemed  dangerous,  shall  certify  its  opinion  to  that  effect  to  the  governor,  who 
may  cause  such  person  to  be  removed  to  an  asylum  and  detained  during  the  continuance 
of  such  insanity. 

Any  justice  of  the  supreme  court  may,  upon  proper  petition,  order  an  examination 
of  any  person  confined  in  any  jail  or  prison,  and  if  such  person  is  found  to  be  insane  or 
idiotic,  or  in  such  a  state  of  impairment  of  mind  or  body  as  tends  directly  thereto,  may 
order  the  removal  of  such  prisoner  to  an  asylum. 

Upon  restoration  to  reason  or  health,  such  person  may  be  remanded  to  the  place  of 
his  original  confinement  by  any  justice  of  the  supreme  court. 

The  agent  of  State  charities  and  corrrection  and  the  secretary  of  State  shall  constitute 
a  commission  to  receive  and  examine  all  complaints  and  letters  from  or  in  relation  to 
any  inmate  of  any  insane  asylum,  or  any  person  alleged  to  be  insane  restrained  of  his 
liberty. 

They  may,  in  their  discretion,  cause  an  examination  to  be  made,  and  may  petition  a 
supreme  court  justice  for  a  formal  investigation.  Such  justice  may  thereupon,  in  his 
discretion,  cause  such  person  so  restrained  to  be  discharged. 


666  APPENDIX   A. 

Such  commission  from  time  to  time,  in  its  discretion,  shall  visit  all  asylums  or  institu- 
tions for  the  insane  and  examine  into  the  condition  and  complaints  of  anyone  so  confined. 

Superintendents  and  others  in  charge,  where  any  insane  person  is  confined,  must  in  no 
way  hinder  or  prevent  any  person  so  confined  from  communicating  with  said  commission, 
and  must  forward  all  communications  to  such  commission  without  delay. 

Whenever  the  agent  of  State  charities  and  correction  shall  make  complaint  to  the 
supreme  court  that  any  person,  reputed  to  be  idiotic,  lunatic,  or  insane,  is  not  humanely 
or  properly  cared  for,  or  is  improperly  restrained  of  his  liberty,  the  court  shall  cause 
examination  to  be  made,  and,  if  found  true,  such  person  shall  be  removed  to  the  State 
Asylum  for  the  Insane. — Sees.  1-40  inclusive. 


SOUTH  CAROLINA. 

[See  General  Statutes  of  South  Carolina,  1882,  sees.  52,  899,  and  1584-1604  inclusive; 
also  sees.  2697-269S;  also  Code  of  Civil  Procedure,  as  adopted,  1881-1882,  sees.  37 
and  70.] 

South  Carolina  Lunatic  Asylum  is  in  charge  of  and  controlled  by  nine  regents  ap- 
pointed by  the  governor. —  Gen.  Stais.,  sees.  1584  et  seq. 
Admission  to  asylum  shall  be  as  follows  : 

1.  All  persons  who  shall  be  found  idiots,  or  lunatics,  by  inquisition  from  the  probate 
or  circuit  courts,  or  on  trials  in  the  circuit  where  the  court  shall  order  such  admission. 

2.  Where  it  shall  be  requested  under  the  hand  of  the  husband  or  wife,  or  (where  there 
is  no  husband  or  wife)  of  the  next  of  kin  of  idiot  or  lunatic. 

3.  All  persons  who  shall  be  declared  lunatics,  idiots,  or  epileptics,  after  due  examina- 
tion by  one  trial  justice  and  two  licensed  practicing  physicians  of  the  State.  Where  the 
subject  is  a  pauper,  the  admission  shall  be  at  the  request  of  the  county  commissioners  of 
the  county  wherein  such  pauper  has  a  legal  settlement;  otherwise  the  admission  shall  be 
at  the  request  of  the  husband  or  wife,  or,  where  there  is  no  husband  or  wife,  of  the  next 
of  kin  of  the  idiot,  lunatic,  or  epileptic. — Gen.  Stats.,  sec.  1586. 

In  criminal  cases,  judges  may  send  persons  7ion  covipos  7nentis  to  asylum. —  Gen.  Stats., 
sec.  1589. 

The  judge  of  the  probate  court  may  commit  to  the  asylum  any  dangerous  lunatic. — 
Gen.  Stats.,  sec.  1590;  Code  of  Civil  Procedure,  sec.  70. 

No  person  committed  after  examination  by  trial  justice  and  two  physicians,  or  who 
shall  be  sent  from  a  sister  State,  shall  be  retained  more  than  ten  days  without  an  order 
for  his  retention,  entered  in  the  records  of  the  institution,  after  examination  by  the 
medical  attendants  and  at  least  three  of  the  regents ;  all  papers  must  then  be  sent  to  the 
probate  judge  of  the  county  where  such  lunatic  resides. —  Ge)t.  Stats.,  sec.  1 591. 
,  It  is  the  duty  of  the  regents  to  dismiss  and  cause  to  be  indicted  any  person  employed 
in  the  asylum  who  shall  assault  or  use  unnecessary  violence  towards  any  inmate. —  Gen. 
Stats.,  sec.  1596. 

Every  judge  of  probate  in  his  county  has  jurisdiction  in  cases  of  lunacy,  and  in  relation 
to  the  appointment  and  removal  of  guardians  for  the  insane,  and  the  care  and  disposition 
of  the  estates  of  their  wards. —  Code  of  Civil  Procedure,  sees.  37  and  38. 


TENNESSEE. 

[See  General  Statutes  (Revision,  1871^  sees.  1517-1564,  and  sees.  3681-3719;  Laws 
of  1871,  p.  159;  Laws  of  1877,  p.  71 ;  Laws  of  1883,  p.  195.] 

The  management  of  the  State  asylums  is  vested  in  a  State  board  of  nine  trustees, 
appointed  by  the  governor,  by  and  with  the  advice  and  consent  of  the  Senate. — Laws 
of  iSjJ,  p.  71  ;  and  Laws  of  1883,  p.  195. 

For  admission  of  a  paying  patient  to  the  asylum,  thirteen  weeks'  charge  must  be  paid 
in  advance,  a  bond  given  for  further  necessary  payments  and  expenses,  and  a  certificate 
by  at  least  one  respectable  physician  must  be  filed  with  the  superintendent. 


ABSTRACT    OF   LAWS    RELATING    TO    THE    INSANE.  66^ 

Form  of  Certificate. 

The  undersigned,  being  a  physician  in  regular  practice,  hereby  certifies  that  on  the 

day  of  ,  18  —  ,  I  personally  examined ,  of County, 

State  of  Tennessee,  and  pronounce insane,  and  a  fit  subject  of  care  and  treatment 

in  a  hospital  for  the  insane.     The  patient  is years  of  age ;  is  free  from  infectious 

disease;  has  been  insane  for ;  the  disease  is  (or  is  not)  hereditary;  the  supposed 

predisposing  and  exciting  causes  are ;  is  not  subject  of  epilepsy;  has  (or  has  not) 

attempted  to  commit  violence  on self  or  others. 


This  certificate  should  contain  all  facts  known  to  the  maker  regarding  the  insanity  of 
the  patient,  and  should  be  signed  and  attested  by  a  justice  of  the  peace. 

For  admission  of  non-paying  patients,  a  statement  having  beexi  filed  with  the  justice 
of  the  peace,  alleging  the  insanity  of  the  patient  in  question,  and  giving  the  names  of 
witnesses,  including  one  physician,  who  can  prove  the  sanne,  the  justice  shall  issue  sub- 
poenas to  the  witnesses  named,  and  such  others  as  he  may  deem  proper.  If,  after  such 
inquest,  the  justice  is  satisfied  of  the  truth  of  the  allegations  set  forth  in  the  statement, 
he  shall  cause  the  physician  in  attendance  to  make  out  a  certificate,  shall  himself  certify 
to  his  inquest,  and  attest  the  signature  of  the  physician  under  seal,  and  transmit  the  same 
to  the  clerk  of  the  county  court,  who  shall  take  the  necessary  steps  for  the  commitment 
of  such  insane  person  to  the  asylum. — Laws  of  1871,  pp.  159-163. 

For  proceedings  for  appointment  of  guardians  for  lunatics,  see  Gen.  Stats.,  sec.  3681 
et  seq. 

TEXAS. 

[See  Laws  of  Texas,  third  edition.  Vol.  II.;  Paschal's  Annotated  Digest,  sees.  5828- 
5835;  and  p.  1 115,  art.  5,  sec.  7;  and  sec.  5462.     Laws  of  1876,  chap.  95.] 

If  information  in  writing  be  given  to  any  county  judge  that  any  person  in  his  county 
is  a  lunatic,  and  requires  restraint,  and  said  county  judge  shall  believe  such  information 
to  be  true,  he  shall  order  such  person  to  be  brought  before  him,  and  a  jury  to  be  sum- 
moned. If  the  jury  find  that  such  person  is  insane,  he  shall  be  sent  to  the  asylum,  unless 
some  friend  will  give  a  bond  to  restrain  and  take  proper  care  of  such  lunatic. 

A  copy  of  all  the  proceedings  shall  be  forwarded  to  the  superintendent  of  the  asylum 
before  sending  a  patient  there. 

The  district  court  has  exclusive  jurisdiction  over  the  estates  of  the  insane. 

Guardians  are  appointed,  who  have  the  care  of  the  persons  and  estates  af  the  insane, 
subject  to  the  control  of  the  courts. 

VERMONT.        s 

[Revised  Laws  of  Vermont,  1880.     Laws  of  1882,  pp.  54-58.] 

Supervision  ok  the  Insane.. 

Sec.  2897.  The  general  assembly  shall  elect  biennially,  three  supervisors  of  the  insane, 
who  shall  hold  their  offices  for  two  years  commencing  on  the  first  day  of  the  next  De- 
cember;  and  the  governor  may  fill  any  vacancy  in  the  board  during  said  term.  Two  of 
said  supervisors  shall  be  physicians,  and  none  of  them  shall  be  a  trustee,  superintendent, 
employe,  or  other  officer,  of  an  insane  asylum  in  the  State. 

Sec.  2898.  The  supervisors  shall  visit  every  asylum  for  the  insane  in  the  State  as  of- 
ten as  occasion  requires,  and  one  of  the  board,  as  often  as  once  a  month,  shall  examine 
into  the  condition  of  said  asylums,  the  management  and  treatment  of  the  patients  there- 
in, their  physical  and  mental  condition  and  medical  treatment,  hear  the  grievances  of  the 
patients  apart  from  the  officers  and  keepers,  and  investigate  the  cases  that  in  their  judg- 
ment require  special  investigation,  and  particularly  shall  ascertain  whether  persons  are 
confined  in  any  asylum  who  ought  to  be  discharged,  and  shall  make  such  orders  therein 
as  each  case  requires. 

Sec.  2899.  '^^^  supervisors  shall  make  report  biennially  to  the  governor  and  the  gen- 


668  APPENDIX    A, 

eral  Assembly  of  their  doings,  and  the  conditions  of  the  asylums  and  patients  therein, 
their  physical  and  medical  treatment  and  the  discipline  thereof,  and  of  such  matters  as 
they  deem  advisable. 

Sec.  2900.  The  supervisoi-s  may  administer  oaths,  summon  \\-itnesses  before  them  in  any 
case  under  investigation,  and  discharge  by  their  order,  in  writing,  any  person  confined 
as  a  patient  in  any  asylum  for  the  insane,  whom  they  find  on  investigation  to  be  wrongfully 
confined,  or  whom  they  find  so  far  sane  as  to  waiTant  the  discharge.  But  convicts  sent  to 
an  asylum  from  the  State  prison  or  house  of  correction  who  are  found  sane  before  expira- 
tion of  their  sentence,  shall  not  be  discharged,  but  the  supervisors  shall  order  them  re- 
turned to  the  prison  or  house  of  coiTection.  In  no  case  shall  the  supervisors  order  the 
discharge  of  a  patient  without  giving  the  superintendent  of  the  asylum  an  opportunity  to 
be  heard. 

Sec.  2901.  The  governor  may  refer  the  case  of  any  patient  in  the  asylums  for  the  in- 
sane to  the  supervisoi"S  for  their  investigation.  And  the  supervisors  shall  investigate  such 
cases,  and  by  their  orders  grant  such  relief  as  each  case  requires ;  but  if  they  have  not 
the  power  to  grant  the  necessary  relief,  they  shall,  if  the  patient  is  one  of  the  insane  poor 
of  the  State,  at  the  expense  of  the  State,  cause  such  proceedings  to  be  commenced  in 
court  as  are  required  to  obtain  the  necessary  relief  and  promote  the  ends  of  justice  and 
humanity. 

Sec.  2902.  The  friends  or  relatives  of  a  patient  in  an  asylum  for  the  insane  may  ap- 
ply to  the  supervisors,  by  petition  or  otherwise,  to  inquire  into  the  treatment  and  con- 
finement of  sucli  patient,  and  the  supervisors  shall  take  such  action  upon  such  application 
as  it  requires. 

Sec.  2903.  If  in  their  judgment  an  investigation  is  necessary,  they  shall  appoint  a 
time  and  place  for  hearing,  and  give  such  friends  and  relatives,  and  the  supeiintendent 
of  the  asylum  reasonable  notice  thereof,  and  at  the  time  appointed  shall  hear  such  friends 
or  relatives  and  superintendent,  and  make  such  lawful  orders  as  the  case  requires.  But 
in  no  case  shall  the  supervisors  order  a  discharge  of  a  patient  without  giving  the  super- 
intendent an  opportunity  to  be  heard. 

Sec.  2904.  If  a  person  legally  summoned  as  a  witness  before  the  supervisors  in  be- 
half of  State,  or  summoned  bj'  other  parties,  with  a  tender  of  his  fees,  wilfullj'  or  wrong- 
fully refuses  to  attend  or  testify,  he  shall  be  punished  as  provided  in  section  1546  (sec. 
16&1J. 

Sec.  2905.  If  a  trustee,  superintendent,  employe  or  other  officer  of  an  as)dum  for  the 
insane,  wilfully  and  knowingly  neglects  or  refuses  to  discharge  a  patient  after  such  pa- 
tient has  become  sane  or  after  the  supervisors  have  ordered  his  discharge,  such  trustee, 
superintendent,  employe  or  other  officer  shall  be  fined  not  more  than  five  hundred  dol- 
lars. 

Regul.^tioxs  Conxerning  Admission  to  Insane  Asylums. 

Sec.  2906.  No  person,  except  as  hereinafter  provided,  shall  be  admitted  to  or  detained 
in  an  insane  asylum  as  a  patient  or  inmate,  except  upon  the  certificate  of  such  person's 
insanity  made  by  two  physicians  of  unquestioned  integritj'  and  skill,  residing  in  the 
probate  district  in  which  such  insane  person  resides,  or,  if  such  insane  person  is  not  a 
resident  of  the  State,  in  tlie  probate  district  in  which  the  asylum  is  situated,  or  if  such 
insane  person  is  a  convict  in  the  State  prison  or  house  of  correction,  such  physicians 
may  be  residents  of  the  probate  district  in  which  such  place  of  confinement  is  situated ; 
and  the  two  phvsicians  making  such  certificate  shall  not  be  members  of  the  same  firm,  and 
neither  shall  be  an  officer  of  the  insane  asylum  in  tins  State.  [As  amended  by  Laws  of 
18S2;   also  see  AWc'.] 

Sec.  2907.  Such  certificate  shall  be  made  not  more  than  ten  days  previous  to  the  ad- 
mission of  such  insane  person  to  the  asylum,  and,  with  a  certificate  of  the  judge  of  pro- 
bate of  the  district  in  which  the  physicians  reside,  that  such  physicians  are  of  unques- 
tioned integrity  and  skill  in  their  profession,  shall  be  presented  to  the  proper  officer  of 
tlie  asylum  at  the  time  such  insane  person  is  presented  for  admission. 

Sec.  2908.  The  certificates  of  the  physician  shall  be  given  only  after  a  careful  exami- 
nation of  the  supposed  insane  person  made  not  more  than  five  days  previous  to  making 
the  certificate,  and  the  physician  who  signs  a  certificate  without  making  such  previous 
examination,  shall,  if  the  person  is  admitted  to  an  asylum  upon  the  certificate,  be  fined  not 
less  than  fifty  dollars  nor  more  than  one  hundred  dollars. 

Sec.  2909.  A  person  may  be  leceived  into  an  asylum  without  a  certificate,  upon  the 
order  or  sentence  of  the  supreme  or  county  court,  upon  the  presentation  of  a  certified 
copy  of  the  order  or  sentence. 


ABSTRACT    OF    LAWS    RELATING   TO    THE    INSANE.  669 

Sec.  2910.  A  person  admitted  to  an  asylum  agreeably  to  the  provisions  of  this  chapter 
shall  be  deemed  insane  and  shall  be  subject  to  the  control  and  sanitary  treatment  of  the 
trustees  of  the  asylum,  until  sufficiently  sane  to  warrant  his  release,  or  until  removed  by 
his  friends  or  guardians,  or  otherwise  discharged. 

Sec.  291 1.  A  trustee  or  other  officer  or  employe  of  an  insane  asylum  who  admits 
or  detains  a  person  in  an  asylum,  contrary  to  the  provisions  of  this  chapter,  shall  be  im- 
prisoned in  the  State  prison  not  more  than  three  years. 

Sec.  2912.  The  secretary  of  state  shall  prepare  and  have  printed  and  furnished  to 
each  probate  judge,  blank  certificates  for  the  use  of  such  judges  and  physicians  in  carry- 
ing out  the  provisions  of  this  chapter. 

Chap.  87,  Sec.  1702.  When  a  person  held  in  prison  on  a  charge  of  having  committed  an 
offence  is  not  indicted  by  the  grand  jury  by  reason  of  insanity,  the  grand  jury  shall  so 
certify  to  the  court,  and  thereupon,  if  the  discharge  or  going  at  large  of  such  insane  per- 
son is  deemed  manifestly  dangerous  to  the  community,  the  court  may  order  him  confined 
in  the  county  jail  or  in  the  insane  asylum  at  Brattleboro,  or  some  other  suitable  place,  at 
his  own  expense,  if  he  has  estate  sufficient  for  that  purpose,  and  if  not,  at  the  expense  of 
the  State. 

Sec.  1703.  When  a  person  tried  on  an  indictment  or  information  for  any  crime  or  of- 
fence is  acquitted  by  the  jury  by  reason  of  insanity,  the  jury,  in  giving  their  verdict  of 
not  guilty,  shall  certify  that  it  is  given  for  such  cause,  and  thereupon,  if  the  discharge  or 
going  at  large  of  such  person  is  considered  dangerous  to  the  community,  the  court  may 
order  him,  in  its  discretion,  to  be  confined  in  the  State  prison  or  in  the  insane  asylum  at 
Brattleboro,  on  such  terms  as  the  court  directs.     Also  see  Laws  of  1882,  No.  49. 

Note. 
Laws  of  1S82,  No.  48. 

Sec.  2.  The  next  friend  or  relative  of  a  person  whose  insanity  is  certified  to  as  above 
provided,  may  appeal  from  the  decision  of  the  physicians  so  certifying  him  to  be  insane 
to  the  supervisors  of  the  insane,  which  appeal  shall  be  noted  on  the  certificate.  The  su- 
pervisors shall,  when  such  appeal  is  taken,  forthwith  examine  the  case,  and,  if  in  their 
opinion  there  was  not  sufficient  ground  for  making  such  certificate,  they  shall  avoid  the 
certificate,  otherwise  they  shall  indorse  their  approval  upon  it.  Such  examination  by  the 
supervisors  shall  be  had  in  the  town  where  the  appellant  resides. 

Sec.  3.  When  the  next  friend  or  relative  of  such  a  person  takes  an  appeal  as  above 
provided,  he  shall  not  be  received  in  an  insane  asylum  while  the  appeal  is  pending  before 
the  supervisors.  And  a  trustee  or  other  officer  or  employe  of  an  insane  asylum  who  re- 
ceives or  detains  a  person  in  such  asylum  vi'hose  insanity  is  not  attested  by  a  legal  certifi- 
cate which  has  not  been  appealed  from,  or  by  a  certificate  duly  approved  by  the  supervi- 
sors on  appeal,  shall  be  imprisoned  in  the  state  prison  not  more  than  three  years. 

Sec.  4.  Idiots  and  persons  non  compos,  who  are  not  dangerous,  shall  not  be  confined  in 
an  asylum  for  the  insane.  And  if  any  such  persons  are  so  confined  the  supervisors  of 
the  insane  shall  cause  them  to  be  discharged. 

For  special  act  to  prevent  the  going  at  large  of  lunatics  see  Laws  of  1882,  No.  47. 


VIRGINIA. 

[See  Code  of  Virginia,  1873,  Title  24,  chap.  82,  p.  714;  Title  55,  chap.  201,  sec.  14, 
p.  1241;  Title  55,  chap.  202,  sec.  17,  p.  1247;  Acts  of  Assembly  1874,  chap.  26;  Acts 
of  Assembly  1881-2,  chap.  133.] 

Each  lunatic  asylum  in  the  State  shall  be  under  the  management  of  a  board  of  eleven 
directors,  appointed  by  the  governor. 

The  directors  may  examine  persons  brought  to  the  asylum  as  lunatics,  and  order  those 
found  to  be  such  to  be  received. 

Any  justice  may  cause  any  person  suspected  of  being  a  lunatic  to  be  brought  before 
him,  and  he  and  two  other  justices  shall  inquire  into  the  case,  and  for  that  purpose 
summon  the  physician  of  such  person  (if  any)  and  other  witnesses.  Questions  to  be 
asked  such  witnesses  are  prescribed  by  statute.     If  the  justices  decide  that  such  person 


670 


APPENDIX   A. 


is  a  lunatic,  and  ought  to  be  confined,  they  may  either  surrender  him  to  some  person  who 
will  give  a  sufficient  bond  for  his  care,  or  cause  him  to  be  removed  to  an  asylum.  Upon 
the  arrival  of  such  patient  at  the  asylum,  the  board  of  directors  is  assembled,  and,  if  they 
concur  in  opinion  with  the  justices,  the  patient  is  received. 

A  committee  shall  be  appointed  for  any  person  found  insane,  and  such  committee  shall 
be  entitled  to  the  custody  and  control  of  his  person  when  not  confined  in  an  asylum  or 
jail,  and  shall  take  possession  of  and  manage  and  care  for  his  estate. 

Where  a  court  sees  reasonable  ground  to  doubt  the  sanity  of  a  person  held  for  trial,  it 
shall  suspend  the  trial  and  order  a  special  jury  to  inquire  into  the  fact.  If  the  jury  find 
the  accused  sane  at  the  time  of  their  verdict,  no  other  inquiry  is  made  and  the  trial  pro- 
ceeds ;  if  they  find  him  insane,  they  then  inquire  whether  he  was  so  at  the  time  of  the 
alleged  oftence.  If  they  find  that  he  was,  the  court  may  dismiss  the  prosecution  ;  if  they 
find  that  he  was  not,  the  court  shall  commit  him  to  jail  or  asylum  until  he  is  so  restored 
that  he  can  be  put  upon  his  trial. — Code,  p.  1247,  chap.  202,  title  55. 


WEST  VIRGINIA. 

[See  Revised  Statutes  of  West  Virginia  {1879),  chap.  108  (chap.  58  of  Code),  p.  673; 
Acts  of  W.  Va.,  1881,  p.  266;  Acts  of  W.  Va.,  1882,  pp.  133-137.] 

The  State  Asylum  is  under  the  control  of  a  board  of  nine  directors,  appointed  by  the 
governor,  with  the  advice  and  consent  of  the  Senate. 

Any  one  or  more  of  the  directors,  together  with  the  superintendent  (who  is  a  physician), 
shall  constitute  an  e.Kamining  board,  and  may  examine  persons  brought  to  the  asylum  as 
lunatics,  and  order  those  found  to  be  such  to  be  received. — Acts  of  IV.  Va.,  1882,  p.  135. 

Any  justice  suspecting  a  person  in  his  county  to  be  a  lunatic,  may  issue  a  warrant  and 
cause  such  person  to  be  brought  before  him,  and  an  inquiry  to  be  had,  after  summoning 
a  physician  and  any  other  witnesses.  If  such  person  be  sent  to  the  asylum,  and  the 
examining  board  refuse  to  receive  him,  because,  in  their  opinion,  he  is  not  a  lunatic, 
they  shall  so  certify,  and  such  person  shall  be  conveyed  back  to  the  county  in  which  he 
was  examined  and  there  discharged. — Ibid. 

The  courts  may  appoint  a  committee  for  any  insane  person. 

Such  committee  is  entitled  to  the  custody  and  control  of  the  person  of  his  ward,  when 
he  resides  in  the  State  and  is  not  confined  in  the  hospital  or  jail,  and  to  the  care  and 
control  of  his  estate.  Suitable  bonds  must  be  given,  and  such  committee  is  under  the 
supei"vision  and  control  of  the  courts. 


WISCONSIN. 

[See  Revised  Statutes  of  Wisconsin  (1878),  sees.  580-609;  Laws  of  1880,  chap.  266; 
Laws  of  1881,  chap.  202  and  chap.  298;  Laws  of  1S82,  chap.  283;  Laws  of  18S3, 
chap.  35.] 

The  State  asylums  are  under  the  control  of  the  "  State  Board  of  supervision  of  Wiscon- 
sin charitable,  reformatory  and  penal  institutions."  The  board  consists  of  five  members 
who  receive  salaries,  and  who  are  appointed  by  the  governor  with  the  advice  and  consent 
of  the  Senate.  Said  board  act  as  commissioners  of  lunacy,  and  have  full  power  with  or 
without  expert  assistance  to  investigate  as  to  the  condition  of  any  inmate  of  a  State  asylum, 
to  hear  complaints,  etc.  Inmates  of  asylums  may  send  sealed  letters  to  this  board. — 
Laws  of  1 88 1,  chap.  298. 

AVhenever  any  resident  of  this  State,  or  any  person  found  therein  whose  residence  can- 
not be  ascertained,  shall  be  or  supposed  to  be  insane,  application  may  be  made  in  his  behalf, 
by  any  respectable  citizen,  to  the  judge  of  the  county  court,  judge  of  the  circuit  court, 
or  any  judge  of  a  court  of  record,  in  and  for  the  county  in  which  he  resides,  or,  in  case 
his  residence  is  unknown,  the  county  in  which  he  is  found,  for  a  judicial  inquiry  as  to  his 
mental  condition,  and  for  an  order  of  commitment  to  some  hospital  or  asylum  for  the  insane. 
The  application  shall  be  in  writing,  and  shall  specify  whether  or  not  a  trial  by  jury  is  desired 
by  the  applicant.     On  the  receipt  of  said  petition,  the  judge  to  whom  it  is  addressed  shall 


ABSTRACT    OF   LAWS    RELATING   TO   THE    INSANE.  67 1 

appoint  two  disinterested  physicians,  of  good  repute  for  medical  sl-:ill  and  moral  integrity, 
to  visit  and  examine  the  person  alleged  to  be  insane,  and  such  physicians  shall  proceed, 
without  unnecessary  delay,  to  the  residence  of  the  pei'son  supposed  to  be  insane,  and 
shall,  by  personal  examination  and  inquiry,  satisfy  themselves  fully  as  to  his  condition, 
and  report  the  result  of  their  examination  to  the  judge. — See  Lazvs  of  1883,  chap.  35. 

Such  report  must  be  substantially  in  the  form  of  answers  to  a  series  of  full  questions 
concerning  the  patient,  provided  specifically  by  the  statutes. — See  Laws  of  1883,  chap. 
35  ;   and  Lazvs  of  1881,  chap.  202. 

Upon  receipt  by  the  county  judge  of  such  application  or  petitioi^  he  may,  if  he  deems 
the  public  safety  requires  it,  order  the  sheriff  to  take  and  confine  such  alleged  lunatic, 
pending  further  proceedings,  in  a  specified  place.— Zawj'  of  1 881,  chap.  202. 

Upon  receipt  of  the  report  of  the  examining  physicians,  the  judge  may,  if  no  demand 
has  been  made  for  a  jury,  order  the  commitment  to  an  asylum  of  the  person  in  question, 
or,  if  not  fully  satisfied,  may  make  additional  investigation  of  the  case.  At  any  stage  of 
the  examination,  the  person  alleged  to  be  insane,  or  his  friends,  may  demand  a  jury  trial, 
and  have  the  right  to  be  assisted  by  counsel. — Laws  of  1880,  chap.  266. 

Upon  application  by  any  i-espectable  citizen,  there  may  be  a  rehearing  and  further 
inquiry  as  to  any  person  confined  in  an  asylum,  or  other  place  of  confinement,  upon 
commitment  as  an  insane  person. — Laws  of  1S81,  chap.  202. 

No  physically  infirm  or  mentally  imbecile  person,  not  deemed  to  be  dangerous  when 
at  large,  shall  be  committed  as  an  insane  person  to  any  hospital  or  asylum  for  the  insane 
solely  because  of  such  infirmity  or  imbecility. — Laws  of  1881,  chap.  202,  sec.  6. 

Guardians  may  be  appointed  for  the  insane,  by  the  county  courts,  to  take  care  of  the 
estates  of  their  wards. — J^ev.  Stats.,  sec.  3989  et  seq. 

Abuse  or  neglect  of  inmate  of  any  hospital  for  the  insane  is  punishable  by  imprison- 
ment for  one  year,  or  by  fine  of  two  hundi-ed  dollars. — Kev.  Stats.,  sec.  4389. 


APPENDIX   B. 


r 


,  SUNNYSIDE  -p, 

Admitted.  ^       MEDICAL  RETREAT.       Discharged. 


Name. 


Age. 


Nativity. 


Date. 


Disease. 


Date. 


Name. 


Quei'ies  for  Patients'  Fj'iends  to  a7iswer,  to  instire  ufiifonnity  of  results  by 
Physicians  in  keeping  record  of  cases. 


QUERIES. 

ANSWERS. 

I.  What  is  the  name  of  the  patient  ? 

Age? 

Place  of  birth  ? 

Residence? 

2.  Is  the  patient  married,  or  single,  or  wid- 
owed ? 

How  long  since  first  married  or  widowed  ? 

If  patient  has  had  children,  state   their  num- 
ber, and  the  date  of  the  birth  of  the  last. 

3.  What  is  the  profession  or  occupation,  and 
reputed  pecuniary  circumstances  of  the  patient  ? 

If  a  female,  state  profession  or   occupation, 
etc.,  of  father  or  husband. 

L 

4.  Is  the  patient  a  professor  of  religion  ? 

5.  What  is  the  original  disposition  and  intel- 
lectual capacitj'  of  the  patient? 

Mention  general  habits  of  life,   predominant 
passions  or  prejudices,  and  any  habitual  vice,  or 
intemperance  ;  does  the  patient  use  ardent  spir- 
its, opium,  tobacco,  etc.? 

6.  Horn  long'h-zs,  the  patient  been  insane? 

Did  the  disorder  come  on  gradually  or  sud- 
denly? 

7.  Has  the  patient  been  insane  previously? 

If  so,  specify  the  date,  duration,  ajiiyorm  of 
each  previous  attack. 

SUNNYSIDE    MEDICAL    RETREAT. 


673 


QUERIES. 

ANSWERS. 

8.  How  long  before  accession  of  insanity  were 
any  such  precursory  symptoms  observed  as  the 
following,  viz.  :    unusual   depression    or    eleva- 
tion of  spirits,  or  any  remarkable  alteration  in 
temper,  disposition,  feelings,  opinions,  conduct, 
sleep,  appetite,  state  of  the  bowels,  or  health  of 
the  patient  ? 

Previous  to  these  symptoms,  had  the  patient 
been  remarkable  for  any  degree  of  oddity,  eccen- 
tricity, or  mental  infirmity  ? 

9.    What  have   been,    or  are,   the   prominent 
symptoms  of  the  malady? 

Has  any  obvious  change  in  its  form  occurred  ? 

Does  it  appear  to  be  increasing;,  decreasing,  or 
stationary? 

10.     Are  there  lucid  intervals  or  any  great  re- 
missions or  exacerbations,  and  do  such  changes 
occur  at  uncertain  times,  or  at  stated  periods? 

II.     Does   the   patient  rave    indifferently   on 
various  subjects,  or  chiefly  on  one  ? 

What  is  that  subject? 

Mention    particularly  any  permanent   or  re- 
markable illusions. 

12.    Has   the   patient   ever   threatened   or  at- 
tempted to  commit  suicide  or  any  act  of  self- 
injury  ? 

By  what  means  ? 

Is  the  propensity  now  active? 

13.  Does  the  patient  manifest  any  disposition 
to  injure  other  persons,  and  how  ? 

Or  cherish  any  malicious  design? 

Is  the  morbid  train  of  thought  excited  by  any 
particular  subject  or  event  ? 

14.  Is  the  patient  inclined  to  tear  clothes  or  to 
break  windows  or  furniture  ? 

15.  Since  the  commencement  of  the  insanity, 
what  have  been  the  patient's  habits  ? 

_  State  particularly  whether  the  patient  is  atten- 
tive to  the  calls  of  nature. 

43 


6/4 


APPENDIX    B. 


QUERIES. 

ANSWERS. 

i6.  What  is  supposed  to  have  been  the  excit- 
ing cause  of  the  insanity  ? 

Is  it  a  moral  cause,  such  as  disappointment, 
fright,  love,  etc.,  or  a  physical  cause — fever,  the 
immoderate     use   of   any     intoxicating    agents, 
bodily  injuries,  serious  illness  or  accident  afifect- 
ing  the  nervous  system,  etc,  ? 

17.  Does  any  constitutional  or  hereditary  pre- 
disposition exist  in  the  family  of  the  patient  to 
nervous  affections  ? 

Were  any  relatives  of  the  patient  ever  insane? 

If  so,  state  particularly  whether  on  the  father's 
or  mother's  side,  or  both. 

18.  Was  the  head  of  the  patient  ever  severely 
injured? 

ig.  Is  the  patient  subject  to  periodical  attacks 
of  any  other  malady  ;  to  anj-  unusual  discharge, 
or  to  suppression   or  obstruction   of  any  custo- 
mary   discharge ;    to   sores,   eruptions,   rupture, 
epilepsy,  or  palsy  ? 

Specifj-  any  bodily  infirmitj'  or  disease  of  the 
patient. 

20.  What  has  been  done  for  the  recovery  of 
the  patient  ? 

And  with  what  effect? 

Mention    particularly   whether    depletion    by 
blood-letting,  leeches,  cathartics,  low  diet,  etc., 
has  been  employed,  and  to  what  extent? 

21.  Has   the  patient  been  subject  to  any  me- 
chanical restraint  ? 


If  so,  specify  the  length  of  time  and  the  man- 
ner in  which  the  restraint  was  applied. 


22.  Has  the  patient  ever  been  treated  for  in- 
sanity in  any  other  asylum  for  the  insane  ? 

If  so,  how  often  and  how  long  on  each  occa- 


When,   in  what  state,  and,  if  not  cured,  for 
what  reason  was  the  patient  discharged  ? 


23.  You  are  requested  to  state  any  other  cir- 
cumstances which  you  may  think  of  interest  or 
importance. 


APPENDIX   C. 


RESUME  OF  TREATMENT  OF  THE  INSANE. 


Priviarily,  give  plenty  of  nutritive  food,  and  give  barks,  wine  and  iron,  or  malt  liquors, 
when  indicated. 

Warm  clothing  and  bedding,  and  a  moderately  warm  and  dry  atmosphere,  and  plenty 
of  occupation  and  exercise, — a  sine  qua  non  in  the  treatment  of  the  insane,  and  change  of 
scene  and  surroundings. 


R.  Fl.  Ext.  Hyoscyami, 

. 

.     gtt.x. 

Am.  Tinct.  I.upulin, 

. 

■    SJ- 

Camphorse  fNeergaard), 

.     gr.  V  to  X. 

Syr.  Aurantii,  , 

. 

•    S'J. 

Aquse  Camph., 

•    5^1- 

M. 

et  ft.  haust. 

Useful  in  asthenic  cases  as  narcotic  and  sedative. 

A  good  sedative  pill  in  general  paralysis  of  the  insane,  and  in  incipient  mental  disor- 
der, with  some  excitability,  is  the  following ; 


R.  Zinci  Valerianat.,      .........  ^J* 

Ext.  Belladonna, gr-  ij- 

M.   et  ft.  pil.  No.   30.     Sig,  Pill  every  2  hours. 

Narcotic  friction  of  scalp  with  Ungt.  Bellad.  Comp.  is  also  old,  but  useful  at  times. 

R.   Ext.  Belladonna  (Allen's), ■^]. 

Morphia  Sulph.,       .          .          .          .          .         .         .         .         •  3J- 

M.  et  ft.  unrt. 


To  subdue  inordinate  excitement,  use  the  prolonged  warm  bath  with  cold  effusions  to 
head,  protracted  an  hour  or  two,  and  followed,  if  necessary,  by  pill  of  camphor,  turpen- 
tine and  hyoscyamus. 

Narcotic  baths  of  albs,  of  henbane,  belladonna,  hemlock,  and  cherry  laurel  leaves,  in- 
fused in  hot  bath,  are  excellent,  even  though  old. 

Tinct.  digitalis,  carried  to  60  minims  ter  die,  after  a  mercurial  cathartic,  produces  sleep, 
quiet,  and  restoration  to  health  in  subacute  mania. 

In  delirium  tremens  ^ -ounce  doses  of  digitalis,  or 

R.  Chloral  Hyd., ^ij. 

Tr.  Hyoscyamus,     .........     _::^ss. 

Syrupi, giv. 

M.  et  sig.    Dose,  tablespoonful,  to  be  repeated  as  necessary. 

Monobromide  of  camphor  in  puerperal  mania,  after  10  grains  of  calomel,  followed  by 
a  saline,  is  a  specific. 


6j6  APPENDIX    C. 

In  nymphomania,  4  grains  camph.  monobromide  everj^  three  hours  after  regulating  se- 
cretion will  suon  cure  the  patient. 

If  nymphomania  is  accompanied  by  clitoric  irritation,  we  may,  with  advantage,  re- 
move the  clitoris. 

In  uterine  irritation  in  insanity,  which  keeps  up  sleeplessness,  use  suppositories  of  I 
grain  stramonium  at  bed-times.  It  quiets  ganglionic  nerves  of  uterus  efficiently,  and  have 
displacement  and  flexion  remedied  at  once. 

In  dysmenorrhoea  in  insanity  use  Schiefflin's  fluid  extract  viburnum  prunifolium  (black 
haw)  ^:^ss  to  3J  every  hour  until  relief  is  experienced.  Very  valuable  in  ordinarj'  dys- 
menorrhoea. 

In  hysteria  and  hysterical  mania,  the  introduction  of  a  litlle  pill  of  ungt.  belladonnas 
comp.  into  the  os  uteri  acts  like  magic. 

R.  Ext.  Belladonn^e  (Allen's), gj. 

Morph.  Sulph., ^j. 

M.  et  ft.  ungt. 

A  combination  of  iron,  phosphorus,  zinc  and  strychnia,  antagonizes  cerebral  degenera- 
tion in  insanity. 

R.  Ferri  Redact.,         .         .         .         .         .         .         .         .         .  gr.  ii. 

Zinci  Phosphidi,     .  .  .         .  .  .  .  .  •  g^-  xV  '^°  3* 

Sti7chniffi  Sulph., gr.  ^1^  to  -J^. 

M.  et  ft.  pil.  No.  I,  t.  i.  d.,  after  meals. 

With  a  moist,  relaxed  state  of  the  skin,  cold  extremities,  shrivelled  surface,  pale  com- 
plexion, and  feeble  circulation,  use  stimulants  and  full  diet,  and  centric  galvanization,  carb. 
am.  or  old  whiskey  or  port. 

In  gi"eat  depression,  melancholia,  especially  if  religious  or  suicidal,  a  course  of  pro- 
longed warm  baths,  with  gradually  increasing  doses  of  morph.  hydrochlorate,  will  antago- 
nize the  morbid  psychic  state  and  cure  the  patient  quickly. 

Enveloping  the  whole  person  in  a  sheet  wrung  out  of  hot  mustard  water,  and  putting 
the  patient  to  bed  is  a  valuable  sedative  measure,  with  dry  cupping  at  back  of  neck. 

Use  all  your  mental  resources  to  weaken  and  dissipate  false  ideas,  a  happy  mixture  of 
kindness  and  firmness. 

Remember,  that  hallucinations  may  be  troublesome  and  disturb  repose,  but  if  the  indi- 
vidual acknowledges  their  falsity,  he  or  she  is  sane.  Prolonged  dry  cupping  may  re- 
lieve this  symptom. 

We  can  control  those  tearing  everything  to  pieces  leaving  themselves  naked,  which  is 
due  to  hypersesthesia  of  the  body,  by  monobromide  of  camph.,  Clin's  capsules  (4  grs.) 
ter  die. 

Fluid  extract  ergot  (Squibb's)  in  2;ss.  to  ^j.  tlirice  daily,  is  the  physiological  antagonist 
to  states  of  recurrent  mania  and  chronic  mania  with  lucid  intervals,  and  also  to  epileptic 
mania;  may  be  combined  with  the  bromides. 

In  states  of  great  motor  excitement  with  homicidal  impulses,  fluid  extract  conium  m^^ 
to  3  }4  doses,  or  ^j,  may  be  used  to  quiet  motor  brain  centres ;  produces  quiei  and  mus- 
cular relaxation. 

Puerperal  mania  is  generally  due  to  the  absorption  of  the  retained  products  of  concep- 
tion, which  causes  sepiicsemia,  and  we  therefore  give  a  mercurial  cathartic,  followed  by 
salines,  and  4  grains  monobromide  camphor  ter  die. 

In  hallucination  with  excitement,  dn-  cups  at  back  of  neck,  prolonged  warm  baths, 
and  30  grains  sodium  bromide,  with  ^o  minims  tinct.  cannabis  indica  in  combination,  ter 
die,  will  produce  quiet  and  tranquillity.     In  dementia  can.  indica  has  noeftect. 

N^onrishment. — The  nourishment  of  a  sane  man  is  generally  insufficient  for  an  insane. 
Full  feeding  means  tranquillity  ;  insufficient  diet,  excitement. 

Diuretics. — When  the  urine  of  the  insane  is  scanty  and  high-colored,  use  diuretics, 
such  as  sp.  ether.,  nit.,  lig.  am.  acetat.,  or  inf.  of  digitalis. 

Carefully  examine  daily  the  state  of  the  pulse  and  skin,  the  head,  the  extremities,  the 
tongue,  the  bowels,  the  urine,  and  regulate  the  catamenia.  If  the  action  of  the  liver  is 
sluggish,  give  dilute  nitro-muriatic  acid,  15  gtt.  in  'Z^]  of  tinct.  gentian,  comp.,  ter  die. 

Restraint. — The  entire  disuse  of  restraint  will  soon  be  possible,  as  insanity  is  gradu- 
ally assuming  in  our  country  a  milder  type  than  formerly.  The  disuse  of  restraint  should 
be  the  rule  and  system. 


RESUME    OF   TREATMENT    OF   THE    INSANE.  6/7 

Occupation  and  exercise  in  the  open  air  for  the  insane  cannot  be  insisted  on  too  strongly 
This,  with  full  feeding  and  warm  baths,  together  with  change  of  scene,  will  cure  many 
patients. . 

Epileptic  and  suicidal  patients  should  always  be  watched  throughout  the  night  by  a 
night  attendant. 

Sleep. — We  should  remeiriber  that  sleep  is  the  first  of  medicines  as  a  physiological  an- 
tagonist to  the  states  of  an  inordinate  degree  of  excitement  and  over  activity  of  nervous 
system  or  mental  anxiety. 

yl/rt'ji'a^e  and  f/^r^reV/Zy  are  of  inestimable  service  in  the  neurasthenia  which  is  often 
the  incipient  stage  of  insanity,  and  rest  for  the  overworked  brain ;  the  galvanic  current 
antagonizes  congestive  states  of  the  brain. 

Proper  diet  and  exercise,  change  of  air  and  scene,  and  useful  and  agreeable  occupation 
of  the  mind,  I  have  come  to  believe,  by  observation,  to  be  the  most  valuable  means  at  our 
command  in  the  treatment  of  insanity. 

By  the  foregoing  we  do  not  at  all  undervalue  the  medicinal  therapeutics  of  insanity 
when  judiciously  applied. 

Disorders  of  the  digestive  organs,  indicated  by  coated  tongue,  constipation,  flatulence 
and  morbid  appetite,  may  be  regulated  by  mist,  rhei,  sodje  and  gentian,  or  the  triplex  pill, 
when  well  made. 

In  recent  cases,  rapid  recovery  may  follow  copious  evacuations  of  the  bowels  and  free 
diuresis,  followed  by  a  course  of  prolonged  warm  baths.  The  latter  calms  general  mental 
excitement  wonderfully. 

The  subsidence  of  excitement  is  not  always  the  immediate  precursor  of  convalescence. 
Having  removed  from  your  patient  all  moral  causes  of  excitement,  do  not  administer 
narcotics  in  large  doses,  but  be  content  to  apply  remedies  calculated  to  correct  the  dis- 
orders of  the  other  bodily  functions,  and  time,  with  good  hygiene,  will  often  cure  your 
patient. 

Sleeplessness,  accompanied  by  high  nervous  excitement,  is  more  safely  combated  by  pro- 
longed warm  baths,  with  cold  to  the  head,  than  by  medicine,  and  tranquillity  and  unin- 
terrupted rest  will  often  follow. 

Insanity  is  a  disease  generally  accompanied  by  bodily  disorders,  and  these  we  must 
remedy.  When  the  digestive  organs  have  resumed  their  healthy  condition,  when  the  pulse 
becomes  natural,  and  there  is  no  unusul  heat  or  dryness  of  the  skin,  we  must  rely  on 
time  and  moral  treatment  to  cure  our  patient. 

Importance  of  Good  Nurses. — Have  no  nurse  for  your  sick  insane  patient,  either  male 
or  female,  with  whom  you  could  not  place  your  wives,  brothers  or  sisters,  and  always 
treat  your  patient  with  the  utmost  attention,  delicacy  and  respect.  They  always  respond 
to  such  treatment. 

When  the  mind  is  weak,  but  slowly  recovering  its  vigor,  a  good  nurse  will  keep  a  pa- 
tient ordinarily  cheerful  and  happy,  while  a  poor  one  will  throw  the  patient  into  a  state 
of  anxiety  and  depression.  A  good  nurse  will  have  the  confidence,  respect  and  affection 
of  her  patient. 

W^e  must  remember  that  a  suicidal  patient  is  a  recoverable  case,  but  they  are  always 
on  the  look-out  for  means  of  self-destruction,  and    the  nurse  must  exercise  unremitting 
vigilant  watching;   when  the  suicidal  act  has  once  been  vci&i]\\.2X^A,  it  is  an  imperative  . 
duty  to  watch  such  a  patient. 

While  we  can  often  trust  the  veracity  of  the  insane,  as  to  going  and  coming  punctually, 
it  is  not  safe  to  do  this  when  the  hazard  is  that  of  life  in  a  suicidal  patient.  Such  patients 
often  throw  the  inexperienced  and  unskilled  off  their  guard  and  commit  suicide. 

We  can  inculcate  self-respect  and  self-control  more  often  in  mental  disease  than  many 
imagine.  Hardly  any  insane  man  or  woman  is  beyond  the  reach  of  a  motive  if  rightly 
presented. 

The  wfird  of  a  violent  patient  to  be  quiet,  industrious,  and  orderly,  is  often  to  be  relied 
on  in  hospital  treatment,  and  we  thus  avoid  the  use  of  restraint. 

I  have  often  heard  the  insane  express  regret  for  their  acts  and  language,  and  have  seen 
them  behave  afterwards  with  perfect  propriety.  In  matters  of  religion  and  morality  we 
should  treat  the  insane  as  sane  while  under  hospital  treatment,  and  inculcate  self-respect 
and  self-control  constantly.     Inculcate  in  such  patients  all  the  habits  of  rational  life. 

Treat  them  kindly  and  politely,  inquire  after  their  health,  hear  patiently  their  stories, 
and  we  shall  thus  gain  their  affection  and  confidence.  Respect  your  patient,  and  he  or 
she  will  respect  themselves.  Treat  them  as  rational  beings,  and  they  will  re-pond  every 
time.     Trust  your  patient,  unless  suicidal,  and  he  will  rarely  abuse  your  confidence.     Let 


6/8 


APPENDIX    C. 


your  intercourse  with  your  patient  be  familiar  and  parental,  and  use  a  mild  and  gentle 
tone  in  speaking  to  them.  Encourage  and  cheer  them  when  despondent ;  soothe  and 
calm  excitement,  and  do  not  leave  your  patient,  if  possible,  until  you  have  done  this. 

Never  lay  violent  hands  on  any  patient,  except  in  self-defence,  which  is  very  rarely 
necessary;  and  never  cower  or  allow  yourself  to  be  looked  out  of  countenance.  See 
that  patients  have  a  pleasant  and  comfortable  temperature  and  light  cheerful  games  and 
amusements.  Provide  neatly  furnished  rooms  to  add  to  your  patients'  self-respect,  and 
provide  good  garments  for  them.  Finally,  provide  easy  and  pleasant  occupation  for 
your  patients,  and  they  will  be  contented  and  happy. 


APPENDIX    D. 


CASES  ILLUSTRATED  BY  THE  PORTRAITS  IN 
FRONTISPIECE. 

No.  I,  in  the  upper  left-hand  corner,  is  the  portrait  of  a  case  of  suicidal  melancholia, 
in  an  Italian  forty  years  of  age.  The  cause  of  the  insanity  was  supposed  to  be  grief  on 
account  of  an  unfortunate  love  affair  in  Italy,  after  which  he  came  to  this  country,  and 
soon  after  landing  became  insane.  No  family  history  could  be  obtained.  He  refused  all 
food,  tried  to  starve  himself  to  death,  and  was  fed  by  the  stomach-tube  for  sixty-three  days. 

No.  2,  in  the  upper  right-hand  corner,  is  the  portrait  of  a  case  of  dementia,  following 
acute  dementia,  she  was  very  violent  and  dangerous  at  times.  Was  suspicious  and 
watchful,  with  delusions  of  fear  and  persecution  while  maniacal.  Her  face  exhibits  her 
disposition  very  well.      Sullen,  taciturn,  and  ever  ready  for  mischief. 

No.  3,  in  the  centre,  represents  a  case  of  epileptic  mania,  iji  a  German  twenty-eight 
years  of  age,  on  the  verge  of  dementia.  Has  been  epileptic  from  youth  up,  and  has 
violent  maniacal  attacks  preceding  the  epileptic  paroxysm,  during  which  he  is  homicidal, 
requiring  restraint.  In  the  interval  between  the  paroxysms,  he  worked  in  the  wards  of 
the  asylum  of  which  he  was  an  inmate,  and  was  quiet  and  polite  unless  instated  or 
annoyed. 

No.  4,  in  the  lower  left-hand  comer,  is  the  portrait  of  a  case  of  dementia,  having  passed 
through  the  stages  of  depression  and  mania.  She  was  good-natured  and  happy,  always 
laughing,  but  had  not  the  slightest  trace  of  intellectual  power  left. 

No.  5,  in  the  lower  right-hand  corner,  is  the  portrait  of  a  case  of  general  paralysis  of 
the  insane,  or  paralytic  dementia.  He  was  a  typical  case,  having  the  shuffling  gait,  the 
slurring  speech,  the  delusions  of  wealth  and  grandeur,  and  more  or  less  delirium  at  times. 

Every  portrait  in  this  plate  expresses  very  well  the  physical  state  of  the  individual  it 
depicts.     The  physiognomy  of  the  insane  is  here  seen  most  typically. 


APPENDIX  E. 


LITERATURE  OF   DISEASES  OF  THE  MIND. 

1689.  Johannis  Helfrici — Praxis  ]\Iedica.     Articles — Mania  and  Melancholia. 

1 71 2.  EtmuUer — EtmuUerus  abridged,  etc.,  translated  1712.  Article — Deficiency  of 
Rational  Operations. 

17 16.  Salmon — The  Practice  of  Physic,  etc.  Articles — Hypochondriac  Diseases  in 
Men  and  Hysteric  in  Women  and  Madness. 

1730.  Shaw — A  new  Practice  of  Physic,  etc.     Articles — Madness  and  Hypochondriasis. 

1763.  Sauvages — "  Nosologia  Methodica." 

1 763.  Mead — The  Medical  Work  of  Dr.  Richard  Mead.  Articles — Madness  and  Hypo- 
chondriasis. 

1765.  Brookes — The  General  Practice  of  Physic,  etc.,  by  R.  Brookes,  M.D.  Articles — 
Hypochondriasis  and  Madness. 

1773.  Gregory — -Manuscript  Notes  on  the  Lectures  of  John  Gregory',  M.D.  Articles — 
Mania  and  Melancholia. 

1791.  CuUen — First  Lines  on  the  Practice  of  Phj'sic.  By  Win.  Cullen,  Prof,  in  the 
University  of  Edinburgh.     Articles — Mania  and  Melancholia. 

1792.  Daquin — La  Philosophic  de  la  Folic,  etc.  Physician  to  Hospital  for  Insane 
and  Hotel-Dieu  of  Chambery. 

1792.   Fodere — On  Cretinism. 

1797.  Darwin — Zoouomia,  etc.  By  Erasmus  Darwin,  M.D.  Articles — Insanity  and 
Hypochondriasis. 

1 801.  Motherby — A  new  Medical  Dictionary,  etc.     Article — On  Insanity. 

1802.  Villermay — Recherches  Historiques  et  Medicales  sur  L'Hypocondrie,  etc.  By 
Sec.  Louyer  Villermay,  Physician,  etc. 

1802.  Denman — An  Introduction  to  the  Practice  of  Alidwifery.     Article — On  Mania. 

1806.  Co.K — Practical  Observations  on  Insanity,  etc.     Second  edition. 

1806.  Reese — On  Melancholia,  in  a  Practical  Dictionary,  etc. 

1809.  Pinel — Traite  Medico-Philosophique  sur  I'alienation  Mentale.  By  Ph.  Pinel, 
consulting  physician  to  his  Majesty  the  Emperor,  etc.  Second  edition.  Also  in  1809 
Hofifbauer  of  Halle  on  "  Psychology  in  its  Chief  Applications  to  the  Administration  of 
Justice." 

1809.  Ha<lam — Observations  on  Madness  and  Melancholy.  By  John  Haslam.  Second 
edition.     Also  "  Medical  Jurisprudence  as  it  Relates  to  Insanity." 

181 1.  Crowther— Practical  Remarks  on  Insanity,  etc.  By  Bryan  Crowther,  member 
of  Royal  College  of  Surgeons,  and  Surgeon  to  Bridewell  and  Bethlem  Hospital. 

1S12.   Dubuisson — ^Dissertation  sur  la  Manie. 

1830.  Rush — Medical  Inquiries  and  Observations  upon  the  Diseases  of  the  Mind.  By 
Benjamin  Rush,  M.D.,  Prof,  of  the  Institutes  and  Practice  of  Medicine  and  of  Clinical 
Medicine  m  the  University  of  Pennsylvania.     Fourth  edition.     Date  of  preface  1812. 

1821.  Armstrong — Practical  Illustrations  of  Typhus  Fever,  etc.     Article — Insanity. 

1817.  Mayo — Remarks  on  Insanity,  etc.  By  Thomas  Mayo,  B.M.,  Fellow  of  Oriel 
College,  Oxford. 

1 81 7.  Thomas — The  Modern  Practice  of  Physic,  etc.     Article — Madness. 

1817.  Spurzheim — Observations  on  the  Deranged  ]Manifestations  of  the  ^lind,  or  In- 
sanity. 

1818.  Hallaran — Practical  Observations  on  the  Causes  and  Cureof  Insanity.  By  Wm. 
S.  Hallaran,  M.D.,  physician  to  the  Lunatic  Asylum  of  Cork.     Second  edition. 


LITERATURE   OF    DISEASES    OF   THE    MIND.  68 1 

1820.  Georget — De  la  FoHe,  etc.  Par  M.  Georget,  Docteur  en  Medecine  de  la  Faculty 
de  Paris,  Ancien  Interne  de  ire  classe  de  la  division  des  alienees  de  I'Hospice  de  la 
Salpetriere.  Also  in  1827  "Des  Maladies  Mentales  Considerees  dans  leurs  Rapports 
avec  la  Legislation  Civille  et  Criminelle." 

1823.  Willis — A  Treatise  on  Mental  Derangement.  By  Francis  Willis,  Fellow  of  the 
Royal  College  of  Physicians. 

1823.  Chapman — Elements  of  Therapeutics,  etc.     Article — On  Mania. 

1823.   Broussais — Monograph  on  Insanity. 

1826.  Guislain — Traite  sur  I'Alienation  iVIentale,  etc.  Par  Joseph  Guislain,  Medecin  k 
Gand.     A  Prize  Essay. 

1826.  Calmeil — De  la  Paralysie  consid^ree  chez  les  Alienes,  etc.  Par  L.  H.  Calmeil, 
Docteur  en  medecine  de  la  Faculte  de  Paris,  Premier  Interne  en  medecine  k  la  Maison 
Royale  des  alienes  de  Charenton. 

1826.  Voison— Des  Causes  Morales  et  Physiques  des  Maladies  Mentales. 

1827.  Knight— Observation  on  the  Causes,  etc.,  of  Derangement  of  the  Mind,  founded 
on  an  extensive  Moral  and  Medical  Practice  in  the  treatment  of  Lunatics.  By  Paul 
Slade  Knight,  many  years  Surgeon  of  the  Lunatic  Asylum  for  the  county  of  Lancaster, 
etc. 

1827.  Seyer — A  Dissertation  on  the  Features  and  Treatment  of  Insanity. 

1828.  Burrows — Commentaries  on  the  causes,  etc.,  and  Treatment,  etc.,  of  Insanity. 
By  George  Mann  Burrows,  M.D.,  member  of  the  Royal  College  of  Physicians  of  London. 

1829.  Gregory — Elements  of  the  Theory  and  Practice  of  Physic.  By  George  Gregory, 
M.D.     Article— Mania. 

1831.  Combe — Observations  on  Mental  Derangement,  etc.     By  Andrew  Combe,  M.D. 

1832.  Seymour — Observations  on  the  Medical  Treatment  of  Insanity. 
1832    Andral^Monograph  on  Insanity. 

1832.  Esquirol — Observations  on  the  Illusions  of  the  Insane,  and  on  the  Medico-legal 
question  of  their  confinement,  etc.     Maladies  Mentales. 
1836.  Neville — On  Insanity,  its  nature,  etc. 

1836.  Allen — Essay  on  the  Classification  of  the  Insane. 

1837.  Mackintosh — Principles  and  Practice  of  Physic.  By  John  Mackintosh,  lecturer, 
etc.     Articles — Insanity  and  Hypochondriasis. 

1837.  Prichard — A  Treatise  on  Insanity,  etc.  By  James  Cowles  Prichard,  M.D., 
F.R.S.,  etc.     American  edition. 

1838.  Ellis — A  Treatise  on  the  Nature,  Symptoms,  Causes  and  Treatment  of  Insanity, 
etc.     By  Sir  W.  C.  Ellis,  M.D.,  etc. 

1838.  Eberle — A  Treatise  on  the  Practice  of  Medicine.  Article — Mental  Derange- 
ment. 

1838.  Mayo — Elements  of  the  Pathology  of  the  Human  Mind. 

1838.  Esquirol — Des  Maladies  Mentales,  etc.  By  E.  Esquirol,  the  M6decin  en  chef 
of  the  Asylum  at  Charenton. 

1839.  Hill — A  Lecture  on  the  Management  of  Lunatic  Asylums,  and  the  Treatment  of 
the  Insane.     By  Robert  Gardiner  Hill,  House  Surgeon  of  the  Lincoln  Lunatic  Asylum. 

1839.  Trelat — Recherches  Historiques  sur  la  Folic.     Par  Ulysses  Trelat,  Docteur  en 
Medecin,  Ancien  Interne  de  la  Maison  des  Alienes  de  Charenton. 
1839.   Cazauvieilh — Du  Suicide  de  I'Alienation  Mentale,  etc. 

1839.  Hooper — Lexicon  Medicum,  etc.     Articles — Mania  and  Melancholia. 

1840.  Morison — The  Physiognomy  of  Mental  Diseases.  Hy  Sir  Alex.  Morison,  M.D., 
Physician  of  Bethlem  Hospital,  the  Surrey  Asylum,  etc. 

1840.  Leuret — Du  Traitement  Moral  de  la  Folic.  By  F.  Leuret,  Physician  to  the 
Bicetre. 

1840.  Dr.  W.  A.  F.  Browne — Supt.  Crichton  I^unatic  Asylum  at  Dumfries.  Article — 
On  Asylums.     Article — Mania. 

1841.  Bingham — Observation  on  the  Religious  Delusions  of  Insane  Persons. 

1841.  Millingen — Aphorisms  on  the  Treatment  and   Management  of  the  Insane,  etc. 
By  J.  S.  Millingen,  late  Med.  Supt.  Hanwell  Asylum. 
1841.   Dr.  Bell — Report  of  Utica  Asylum  for  the  Insane. 

1841.  Dr.  Kirkbride — -Report  of  Pennsylvania  Hospital  for  the  Insane. 

1842.  Westminister  Review—  Non-Restraint.     Article. 
1842.   McCormac— Methodus  Medendi,  etc.     Article — Mania. 

1842.   Dr.   Forbes  Winslow — On  the  Preservation  of  the  Health  of  Body  and  Mind. 
By  Forbes  Winslow,  member  of  the  Royal  College  of  Surgeons  of  London,  etc. 
1842.  Crichton — Reflections  on  Remedial  Treatment.     By  Sir  Alex.  Crichton. 


682  APPENDIX   E. 

1842.  Dr.  Brigham — Report  of  Hartford  Retreat  for  1842. 

1842.  Earle — Letter  by  Pliny  Earle,  M.D.,  on  Treatment  of  Insanity 

1842.  Dunglison — The  Practice  of  Medicine,  etc.     Article — Mental  Alienation. 
1842  and  '43.  Reports  of  Visiting   Committee  of  the   County  Lunatic  Asylum  near 

Gloucester,  England. 

1843.  Falret — Considerations  Generales  sur  les  Maladies  Mentales,  par  M.  Falret, 
Medecin  en  chef  de  1' Hospice  de  la  Salpetriere,  etc. 

1843.  Southerland — Clinical  Lectures  on  the  Theory  and  Medical  Treatment  of  In- 
sanity. 

1844.  Ray — Report  of  Maine  Insane  Asylums.     Remarks  on  Restraint. 
1844.  Bell — Report  of  McLean  Asylum.     Remarks  on  Restraint. 

1844.  Dr.  Earle — -Report  of  Bloomingdale  Asylum.     Means  of  Bodily  Restraint. 

1844.  Dr.  Brigham,  of  Utica  Asylum— Treatment  of  Violent  Maniacs. 

1844.  Dr.  Kirkbride,  of  the  Pennsylvania  Hospital  for  the  Insane — Restraint  and  its 
abuse  in  European  Institutions. 

1844.  Dr.  Samuel  B.  Woodward — Report  of  Massachusetts  State  Lunatic  Hospital  at 
Worcester.     Remarks  on  Treatment  of  Insanit}'. 

1844.  Pinel — Traite  de  Pathologic  Cerebrale,  etc.  Par  Scipion  Pinel,  Ancien  Mede- 
cin des  Alienes  de  la  Salpetriere  et  de  Bicetre,  etc. 

1845.  J.  Moreau  fdu  Tours) — Du  Hachish,  etc.  Par  J.  Moreau  (de  Tours),  Medecin 
de  r Hospice  de  Bice:re,  etc. 

1845.  -De  Boismont — ^Des  Hallucinations,  etc.  Par  A.  Brierre  de  Boismont,  Doc- 
teur  en  Medecin  de  la  Faculte  de  Paris. 

1844-45.  Report  of  the  Metropolitan  Commissioners  in  Lunacy  to  the  Lord  Chancellor. 

The  following  is  a  List  of  the  Chief  Authors  who  have  Written  on  Mental 
Diseases  since  1845,  without  Reference  to  Chronological  Order. 

Boyd,  Dr. — Vital  Statistics,  Journal  of  Mental  Science,  January,  1865,  p.  61. 

Bucknill  and  Tuke,  Drs. — INIanual  of  Psychological  Medicine. 

Clouston,  Dr.  T.  S. — On  Tuberculosis  and  Insanity,  Journal  Mental  Science,  April,  1863 

Griesinger,  Dr.  W. — Die  Pathologic  und  Therapie  der  Psychischen  Krankheiten. 

Haslam,  Dr.  J. — The  Sound  ^lind. 

Hammond — On  Insanity ;  also  article  in  Diseases  of  Nervous  System. 

Leidesdorf,  Dr.  M. — Die  Pathologic  und  Therapie  der  Psychischen  Krankheiten. 

Moreau,  Dr.  J.— Psychologic  Morbide. 

Morel,  Dr.  B. — Traite  des  Degenerescences  Physiques  Intellectuelles  et  Morales. 

Mugier,  Dr.  E. — De  la  Folie  Consecutive  aux  5laladies  Aigues. 

Maudsley,  Dr.  Henry — Aiticle  on  Insanity  in  Reynolds's  System  of  Medicine,  Second 
Edition.     The  Physiology  and  Pathology  of  Mind.     Body  and  Mind. 

Parchappe — Traite  de  la  Folie. 

Schroeder  van  der  Kolk — Die  Pathologic  und  Therapie  der  Geisteskrankheiten. 

Skae,  Dr    D. — On  Rational  Classification  of  Insanity. 

Solomon,  Dr.  E. — On  the  Pathology  of  General  Paralysis,  in  Journal  of  Mental  Sci- 
ence, October,  1862. 

Spitzka,  Dr.  E.  C. — On  Insanity. 

Wilks,  Dr.  J. — On  Atrophy  of  the  Brain,  in  Journal  of  Mental  Science,  October,  1864. 

Reynolds,  Dr.  J.  Russell — On  Softening  of  the  Brain.  Also,  on  the  same  subject,  see 
Abercrombie  on  Diseases  of  the  Brain  and  Spinal  Cord,  p.  462.  Andral,  Hughes  Ben- 
ivett,  Boulland,  Broca,  Cruveilhier,  Durand  Fardel,  Gluge,  Hughlings  Jackson,  Kirkes, 
Laborde,  Lallemand,  Lancereaux,  Prevost  and  Cotard,  Rokitansky,  Rostan,Todd,  Trous- 
seau, etc.,  etc. 

West  Riding  Lunatic  Asylum  Reports.     By  Dr.  Crichton  Browne. 

Journal  of  Mental  Science  from  18 —  to  1883. 

London  Journal  of  Psychological  Medicine  and  Mental  Pathology  from  1848  to  1883. 

Forbes  Winslow,  M.D.,  D  C.L.  Oxon. — i.  Obscure  Diseases  of  the  Brain  and  Mind.  2. 
The  Anatomy  of  Suicide.  3.  Lettsomian  Lectures  on  Insanity.  4.  The  Plea  of  Insanity  in 
Criminal  Cases.  5.  Medico-Legal  Comments  on  the  Insanity  of  Buranelli,  Executed  for 
Murder.  6.  Uncontrollable  Drunkenness  Viewed  as  a  Form  of  Insanity.  7.  Winslow's 
Manual  of  Lunacy.     8.  A  Lunacy  Chart. 

Routh,  Dr.  C.  H.  F.,  Senior  Physician  to  Samaritan  Hospital  for  AVomen  and  Children 
— On  Overwork  and  Premature  Mental  Decay. 

Clarke,  Dr.  Edward  H. — The  Building  of  a  Brain. 


LITERATURE    OF    DISEASES    OF   THE    MIND.  683 

Browne,  J.  H.  Balfour,  Barrister-at-law — The  Medical  Jurisprudence  of  Insanity.  Re- 
sponsibility and  Disease. 

Smith,  Dr.  Christopher — On  Mental  Capacity  in  Relation  to  Insanity,  Crime,  and. 
Modern  Society. 

Hyslop,  William — Sermons  for  the  Insane. 

Winn,  Dr.  J.  M. — Nature  and  Treatment  of  Hereditary  Disease.  Plain  Directions  for 
Dealing  with  an  Insane  Patient.  A  Critical  Treatise  on  the  General  Paralysis  of  the  Insane. 

Guy,  Dr.  William — Forensic  Medicine.     The  Factors  of  an  Unsound  Mind. 

Gray,  Dr.  John  P. — The  American  Journal  of  Insanity  since  1854. 

Taylor,  Dr.  Alfred  S. — Medical  Jurisprudence.     A  Manual  of  Medical  Jurisprudence. 

Ogston,  Dr.  Francis — Lectures  on  Medical  Jurisprudence. 

Tidy,  C.  Meymott — A  Handy  Book  of  F"orensic  Medicine  and  Toxicology. 

Sheppard,  Dr.  Edgar,  Professor  of  Psychological  Medicine  in  King's  College — Mad- 
ness in  its  Medical,  Legal,  and  Social  Aspects. 

Ireland,  Dr.  William  W. — Idiocy  and  Imbecility. 

Ross,  Dr.  James — A  Treatise  on  the  Diseases  of  the  Nervous  System.     Article. 

Jones,  Dr.  C.  Hanfield — Studies  in  Functional  Nervous  Disorders.     Article. 

Buzzard,  Dr.  Thomas — Clinical  Lectures  on  Diseases  of  the  Nervous  System.    Article. 

Quain — Dictionary  of  Medicine.     Article — On  Insanity. 

Krafft-Ebbing — Lehrbuch  der  Psychiatrie,  auf  Klinischer  Grundlage,  fuer  praktische 
Aerzte  und  Studirende.     Stuttgart:  Verlag  von  Enke,  1879.     3  vols. 

Voison,  Dr.  Auguste — Traite  de  la  Paralysie  Generale  des  Alienes.  Par  le  Docteur 
Auguste  Voisin,  Medecin  de  I'Hospice  de  la  Salpetriere,  etc.     Paris,  1879. 

Treatment  of  the  Insane  in  the  United  States.  See  Reports  from  Asylums  for  the  In- 
sane in  the  United  States. 

Benedikt,  Dr.  Moritz — Anatomische  Studien  an  Verbrecher-Gehirnen,  fur  Anthropolo- 
gen,  Mediciner  Juristen  und  Psychologen  Bearbeitet.  Wien,  1879.  (Anatomical  Studies 
of  Criminals'  Brains  for  Anthropological,  Medical,  Judicial,  and  Psychological  Research 
and  Purposes.)* 

Bourneville — Epilepsy  and  Hysteria. 

Richet — Cerebral  Convolutions.     Paris,  1878. 

Fournier — Cerebral  Syphilis.     Paris,  1879. 

Lionet — General  Paralysis.     Paris,  1S78. 

Ray,  Dr.  I. — Medical  Jurisprudence  of  Insanity.  Mental  Hygiene.  Contributions 
to  Mental  Pathology,  1873. 

Nothnagel — Diagnosis  of  Brain  Disease.     Berlin,  1879. 

Beard — Neurasthenia.      1880. 

Bastian — The  Brain  as  an  Organ  of  Mind.      1880. 

Jewell,  Dr.  J.  S. — The  Influence  of  our  Present  Civilization  in  the  Production  of  Nerv- 
ous and  Mental  Diseases.  Article  in  Journal  of  Nervous  and  Mental  Diseases,  Janu- 
ary, 1 88 1. 

Morton,  Dr.  W.  J. — The  Town  of  Gheel  in  Belgium  and  its  Insane,  etc.  Article  in 
Journal  of  Nervous  and  Mental  Diseases.     January,  1881. 

Clevenger,  S.  V. — The  Importance  of  the  Position  of  the  Fissure  of  Rolando  as  an 
Index  to  the  Intelligence  of  Animals.  Article  in  Journal  of  Nervous  and  Mental  Dis- 
eases.    April,  1880. 

Kroemer — The  Temperature  of  the  Paralytic  Insane.  Allgem.  Zeitschr.  f.  Psychiatrie, 
xxxvi.,  ii.  and  iii.  Hft. 

Sutherland,  Dr.  H. — Alcoholic  Insanity  in  Private  Practice.  (Paper  read  before  Brit- 
ish Medical  Association  in  1880.) 

Schmidt,  Dr.  Herman — Occurrence  of  Hysteria  in  Children.  Jahrbch.  f.  Kindhlkde., 
XV.  B.,  I  H 

Morton,  Dr.  William  J. — On  Hysteria  Major.  N.  Y.  Medical  Record,  October  2d,  1880. 

Hagenbach,  Dr.  A.  W. — Masturbation  as  a  cause  of  Insanity.  Article  in  Journal  of 
Nervous  and  Mental  Diseases,  October,  1879. 

Ray,  Dr.  I. — Curability  of  Insanity;  (Paper  read  before  the  College  of  Physicians  of 
Philadelphia,  May  7,1879.) 

Jewell,  Dr.  J.  S. — Nervous  Exhaustion  or  Neurasthenia  in  its  Bodily  and  Mental  Re- 
lations.    Three  articles  in  Journal  of  Nervous  and  Mental  Diseases,  l878and  1879. 

*  On  same  subject,  see  works  of  Semet,  Gratiolet,  and  Broca,  in  France ;  Owen  and 
Huxley,  and  their  school,  in  England;  Huschke,  Virchow,  and  Bischoff,  in  Germany ; 
and  Lombroso,  in  Italy. 


684  APPENDIX    E. 

Strieker — Hallucinations.     Wiener  Med.  Blaetter,  1878.     No.  4-6. 

Krafft- Ebbing — The   Menstrual  Psychoses.     Paper  in  the  Archiv.  f.  Psychiatrie,  viii., 

Kiernan,  Dr.  J.  G. — Contributions  to  Psychiatr)'.  Article  in  Journal  of  Nei"vous  and 
Mental  Diseases,  October,  1880. 

Kerlin — Insanity  in  Children.  Paper  in  Proceedings  of  the  Association  of  Medical 
Officers  of  American  Institutions  for  Idiotic  and  Feeble-minded  Persons. 

Drysdale — Syphilitic  Insanity.      1880. 

Andrews,  Dr.  J.  B. — On  Chloral.  American  Journal  of  Insanity,  July,  1871  ;  Asylum 
Management  and  Reform,  pp.  324,  532,  vol.  ii.  ;  Journal  of  Nervous  and  Mental  Diseases, 

Addison,  Dr.  A. — On  Epileptic  Insanity.     Journal  of  Mental  Science,  April,  1866. • 

Aldridge,  Dr.  C. — The  Pupd  in  General  Paralysis.  Vols.  i.  and  ii.,  West  Riding 
Reports. 

AUbutt,  Dr. — The  Ophthalmoscope  in  Diseases  of  the  Nervous  System  ;  Observations 
in  Mania;   Melancholia;    Monomania;  General  Paralysis,  Syphilitic  Insanity,  etc.,  1871. 

Aubanel — On  the  Seasons. 

Auzony,  Dr. — On  Criticism.     Report,  pub.  in  1873,  to  the  French  Commission. 

Bacon,  Dr.— On  the  Handwriting  of  the  Insane.     1870. 

Baillarger — On  Heredity.  Annales  Medico- Psychol.,  1844;  on  Stupidite  ;  on  Mo- 
nomania ;  Hallucinations ;  Folie  a  Double  Forme ;  Febrile  Insanity ;  and  On  Layers 
of  the  Brain. 

Ballardini — ^On  Pellagra.  Notes  on  Pellagra,  Brit,  and  For.  Medico-Chirurgical  Re- 
view, January,   1863. 

Bastian,  Dr. — On  Morbid  Histology  of  Insanity;  on  Specific  Gravity  of  the  Brain. 
Article  in  Journal  of  Medical  Science,  January,  1866. 

Beck — Medical  Jurisprudence. 

Behic,  M. — Lunacy  Reports.     (French.) 

Bemiss,  Dr. — On  Consanguineous  Marriages.  Article  in  Medico-Chirurgical  Review, 
July,  i860. 

Benedict,  Dr. — On  Suicide.     Report  of  New  York  State  Asylum  for  1850. 

Bertrand — On  Suicidal  Mania. 

Blandford,  Dr. — On  Insanity. 

Boerhaave — On  Hypochondriasis  in  Insane  Brains. 

Bonnet — On  Morbid  Histology  of  Insanity. 

Bottex — On  General  Paralysis. 

Bouchard — On  Bloodvessels  in  Insanity. 

Boyd,  Dr.,  Superintendent  Somerset  Co.  Asylum — On  Vital  Statistics,  Journal  of 
Mental  Science,  January,  1865. 

Brierre  de  Boismont — On  .'Etiology  of  Insanity  ;  Cretinism  ;  Dementia  ;  Delusions  ; 
Moral  Insanity  ;  Suicide  ;  General  Paralysis ;  Puerperal  Insanity ;  Pellagrous  Insanity  ; 
Memory  of  the  Insane  ;   Treatment. 

Brigham,  Dr. — Statistics  as  to  Hereditary  Predisposition. 

Brodie,  Sir  Benjamin — On  Humoral  Pathology.  Lectures  on  Surgery  and  Pathology, 
p.  308. 

Bain — On  the  Senses  and  Intellect. 

Brown,  Dr.  Thomas — On  Insanity. 

Browne,  Dr.  Crichton — On  Moral  Insanity  (Journal  of  Mental  Science,  iS6o,p.  314); 
On  Cranial  Impression,  2  articles  in  vols,  i  and  2  of  the  West  Riding  Lunatic  Asylum 
Reports;  On  Homicidal  Mania  (op.  cit.,  p.  310);  Kleptomania  (Journal  of  Mental 
Science,  1866,  p.  311 1 ;  On  Dipsomania  (in  Evidence  before  the  Select  Committee  of  the 
House  of  Commons,  1872,  on  Habitual  Drunkards) ;  Sphygmographic  Tracings  (vol.  I 
of  Reports  of  the  Wakefield  Asylum,  Englandj  ;  Treatment  (see  vol.  ii.  of  West  Riding 
Asylum  Reports). 

Browne,  Dr.  W.  A.  F. — On  Epileptic  Idiocy;  Family  of  Idiots.  Journal  of  Mental 
Science,  October,  1862. 

Briihl,  Cramer — On  Dipsomania,  Berlin,  1819. 

Bucknill,  Dr. — Manual  of  Psychological  Medicine,  Bucknill  and  Tuke. 

Burman,  Dr. — On  General  Paralysis.  Journal  of  Mental  Science,  Januar}',  1873;  on 
Heart  Disease  and  Insanity.  West  Riding  Asylum  Reports,  1S73;  01^  Conium,  vol.  ii. 
of  same  Reports. 

Burrows,    Dr.    G.   M. — On  Heredity;   Sex;   Paralytic  Insanity;   Puerperal  Insanity; 
Melancholia  Attonita;   Treatment. 
Burton — Anatomy  of  Melancholy. 


LITERATURE    OF    DISEASES    OF    THE    MIND.  685 

Buttoiph,  Dr. — On  Insanity  in  General.  See  Reports  of  New  Jersey  State  Asylum  for 
the  Insane. 

Buzzard,  Dr. — Syphilitic  Nervous  Affections. 

Calderini — Notes  on  Pellagra.  Brit,  and  For.  Medico-Chirurgical  Review,  January, 
1863. 

CaJmeil — On  General  Paralysis. 

Calmet — On  Insanity. 

Campbell,  Dr.  John — On  Hyoscyamus,  paper  in  Journal  of  Mental  Science,  No.  80; 
on  Bromide  of  Potash,  paper  in  same  Journal,  Nos.  67  and  80;  on  the  Relative  Epilepsy 
of  Neurotics,  Experiments  Recorded  in  Bucknill  and  Tuke's  Manual  of  Psychological 
Medicine,  4th  ed.,  p.  732. 

Dr.  John  Le  Cappelain's  Table  of  Mortality,  drawn  up  for  the  Massachusetts  Com- 
mission on  Lunacy  in  1855. 

Carpenter,  Dr. — Case  of  Idiocy  in  4th  ed.,  p.  360,   Human  Physiology. 

Casson — Cases  of  General  Paralysis  reported  from  Hull  Borough  Asylum. 

Celsus — On  Insanity. 

Cessatt — On  the  Sporisorium  maydis  (Parasite  in  Pellagra). 

Charcot — On  Aneurisms  of  Bloodvessels  in  Insanity,  Sclerosis  Arteritis.  See  Treatise 
of  MM.  Bouchard  and  Charcot  on  Study  of  some  Points  in  the  Pathology  of  Cerebral 
Haemorrhage,  1872. 

Chesteiton,  M. — On  General  Paralysis  in  Reminiscences  of  Prison  Life.   Kleptomania. 

Dr.  Child — On  Relative  Liability  of  the  Sexes  to  Insanity,  Medico-Chirurgical  Review, 
April,  1862. 

Christison,  Sir  Robert — On  Some  of  the  Medico-legal  relations  of  Intemperance. 
1861. 

Clarke,  Dr.  Lockhart — On  General  Paralysis.  Journal  of  Mental  Science,  No.  72,  also 
Lancet,  September  ist,  1866. 

Dr.  Cleland — On  the  Cerebral  Cells  in  Morbid  Histology  of  Insanity. 

Dr.  Clouston — On  Classification,  Journal  of  Mental  Science,  1873-5,  ^"^  January, 
1876,  Morrisonian  Lectures  ;  on  Intemperance  as  a  cause  of  Insanity  ;  on  Physical  causes 
of  Insanity,  see  Reports  of  the  Royal  Edinburgh  Asylum  ;  on  Rheumatic  Insanity,  Jour- 
nal of  Mental  Science,  July,  1870;  Tul)ercular  Insanity,  Journal  of  Mental  Science, 
April,  1863  ;  on  Treatment,  Journal  of  Mental  Science,  Nos.  67  and  80,  and  Prize  Essay 
in  Brit,  and  For.  Medico-Chirurgical  Review,  October,  1870,  and  January,  187I. 

Crothers,  Dr.  T.  D. — On  Dipsomania.     Article  in  Journal  of  Inebriety. 

Conolly— On  Insanity.     History  of  the  Abolition  of  Mechanical  Restraint,  etc. 

Curling,  M. — On  Sporadic  Cretinism.  Paper  in  1850,  before  the  Royal  Medico-Chirur- 
gical Society. 

Dagonet,  M. — Papers  on  Stupidite  (or  Stupemance),  in  March  number  of  the  Annaler, 
1872.     (Melancholia  Attonita.) 

Daguin — Philosophic  de  la  Folie. 

William  George  H.  Darwin — On  Consanguineous  Marriages.  Statistical  Society's 
Journal,  June,  1875. 

Mr.  H.  Davy — Temperature  in  General  Paralysis,  reported  by  Drs.  Bucknill  and  Tuke, 
p.  319,  4th  ed..  Manual  of  Psychological  Medicine. 

M.   Debryne — On  Suicidal  Mania,  Du  Suicide. 

Dr.  Decaisne — Article  on  Absinthe  and  its  Effects  upon  the  Nervous  System.  la 
the  Gazette  des  Hopiteaux,  1869. 

Deiters — Morbid  Histology  of  Insanity. 

Delasiauve — On  Epileptic  Insanity.     In  Annales,  1852,  p.  491. 

Rev.  Dr.  Denman — Papers  on  the  Dependence  of  Mental  on  Physical  Conditions, 
In  Psychological  Journal. 

Desmaisons — Memoir  on  the  Form  of  the  Head  in  Idiots. 

Despine — Psychologic  Naturelle,  1868. 

Dr.  J.  T.  Dickson — A  Contribution  to  the  Study  of  the  so-called  Puerperal  Insanity. 
Journal  of  Mental  Science,  October,  1870. 

Dr.  Donn — On  Idiocy. 

Dr.  Dowse — On  Syphilis  as  it  Affects  the  Brain  and  Nerves.  Medical  Press  and  Cir- 
cular, 1877,  1878. 

Dr.  Duncan — On  Syphilitic  Insanity.  In  Dublin  Journal  of  Medical  Science,  Febru- 
ary,  1863. 

Earle,  Dr.  Pliny — On  Age ;  Compend  of  Statistics  of  Northampton  Lunatic  Asylum, 
Massachusetts,  relative  to  the  admission  of  1074  patients,  1873  ;   on  Occupation,  p.  75 


686  APPENDIX    E. 

of  same  statistics;  on  Civilization,  see  same  report;  on  Marriage,  see  same  report;  on 
Intemperance,  see  same  statistics  ;  on  Epilepsy,  same  report ;  Moral  and  Physical  Causes, 
same  report;  on  Recoveries,  pamphlet  on  the  Curability  of  Insanity,  1877;  Pupils  in 
Mania,  paper  in  the  American  Journal  of  Insanity,  April.  1854. 

Earle,  Dr.  Pliny — On  Bleeding,  Essay  ;  on  Narcotics,  Opium  and  Morphine. 

Dr.  Echeverria — On  Epileptic  Insanity,  1870.  Paper  on  532  carefully  observed  cases 
of  epilepsy,  read  at  the  Paris  International  Congress,  1878;  Ep.  Insanity,  etc.  Paper 
in  the  American  Journal  of  Insanity,  1873. 

Erlenmeyer — On  Syphilitic  Insanity,  1869,  1870;  on  Analysis  of  Blood  of  the  In- 
sane. 

Esmarch — On  Syphilitic  Insanity,  1857. 

Esquirol — Maladies  Mentales 

Dr.  Fagge — Sporadic  Cretinism  occurring  in  England,  1871.  Paper  before  the 
Medical  and  Chirurgical  Society, 

M    Falret — On  Insanity,  1843. 

Jules  Falret — On  Epilepsy,  Arch.  gen.  de  Med.,  December,  i860;  Alcoholic  Insanity, 
1852 ;  on  the  Action  of  Bromides  on  the  Epileptics  of  the  Bicetre,  in  the  Annales  Medico- 
Psychologiques,  5th  vol.,  5th  serie,  p.  161. 

Dr.  Farr — Statistics  of  Insanity. 

Felix  Plater — On  the  Swiss  Cretins,  1500. 

M.  Ferrus — On  Hsematoma  Auris.     Gazette  des  Hopitaux,  1838. 

Fischer — -On  Hgematoma  Auris.     Journal  of  Mental  Sciences. 

Fleming— On  Classification  of  Insanity.  Allgemeine  Zeitschrift  fiir  Psychiatric,  1844, 
p,  144,  Psychosen,  p.  118,  on  Epilepsy. 

M.  Foville — Observations  on  Insanity,  made  at  the  Salpetriere  and  at  St.  John. 

A.  Foville — On  Dipsomania,  Archiv.  gen.  de  med.,  October,  1867;  on  General  Pa- 
ralysis, Annal.  Med. -Psych.,  January,  1873  >  on  Puerperal  Insanity. 

Franque,  Arnold  von — On  Insanity  of  Gestation  or  Pregnancy.  Wurzburgher  Med. 
Zeitschrift,  1863. 

Dr.   P'raser — On  Idiocy.     In  Journal  of  Mental  Science,  July,  1876. 

Fredrich — On  the  Bodily  Causes  of  Insanity,  1836  and  1839. 

Galen — On  Classification  ;  on  the  Influence  of  the  Moon  on  Hypochondriasis. 

Gall — On  Idiocy  ;  on  Insanity. 

Dr.  Gasquet — On  Pellagrous  Insanity.     Journal  of  Mental  Science,  1872,  p.  582. 

Georget — On  Stupidite  (Acute  Dementia). 

Gerlach — On  the  Cortex  of  the  Cerebrum. 

Dr.  Gooch — On  Puerperal  Insanity. 

Dr.  Grabham — Remarks  on  the  Origin,  etc.,  of  Idiocy,  1875. 

Greding — On  Special  Changes  in  Insanity. 

Dr.  Giiggenbuhl,  of  Switzerland.     On  Cretinism, 

Dr.  Guy — Forensic  Medicine. 

Hseser — Geschichle  der  Epidemischen  Krankheiten. 

Halford,  Sir  H. — Essays  on  Insanity. 

Haller — On  Insane  Brains.     Elements  of  Physiology. 

Hecker — The  Epidemics  of  the  Middle  Ages. 

Heinroth — On  Insanity. 

Helm— On  Puerperal  Insanity,  1 840. 

Hule — On  Morbid  Histology. 

Hildenbrandt — ^De  la  Syphilis  dans  ses  rapports  avec  1' Alienation  Mentale. 

Hittorf — On  the  Blood  of  Insane  Patients,  p.  597,  4th  ed.  Bucknill  and  Tuke's 
Manual  of  Psychological  Medicine. 

Hofifbauer  — On  Insanity. 

Hoffman — On  Post-febrile  Insanity.     Giinsburg  Zeitschrift,  iv. 

Hood,  Sir  Charles — Statistics  of  Bethlem  Hospital. 

Dr.  Howden — On  Epileptic  Insanity,  Journal  of  Mental  Science,  January,  1873  ;  on 
Kidney  Disease  in  the  Insane,  Reports  of  Montrose  Asylum  :  on  Granular  Degeneration 
of  Cells  (paper). 

Dr.  Hun — Hematoma  Auris,  American  Journal  of  Insanity,  July,  1870;  on  Pulse  in 
Insanity,  American  Journal  of  Insanity,  January,  1870. 

Dr.  Magnus  Huss — Alcoholic  Insanity. 

Hutcheson — On  Dipsomania. 

William  J.  Hutcheson — On  the  Teeth  and  Syphilis,  and  Idiocy. 

Dr.  A.  H.  Huth^-The  Marriage  of  near  Kin,  1875. 


LITERATURE   OF    DISEASES    OF   THE    MIND.  68/ 

Dr.  W.  W.  Ireland — Idiocy  and  Imbecility,  1877. 

Jackson,  Dr.  Hughlings — On  Mental  Automatism.     (West  Riding  Medical  Reports, 

Dr.  Max  Jacobi— On  bodily  causes  of  Insanity,  1836-39 ;  on  Relapses ;  on  the  Pulse  in 
Mania ;  on  Treatment. 

Dr.  Jarvis — On  Consanguineous  Marriages ;    Sex  and  Study. 

Dr.  Jenner — On  the  use  of  Antimony  to  the  shaven  scalp. 

Dr.  Jessen — On  Pyromania.  Die  Brandstiftungen  in  Affecten  n.  Geistesstorungen 
(Kiel,  i860). 

Jones,  Dr.  Hanfield — On  Post-febrile  Insanity.  In  Brit.  Med.  Journal,  January  12,  1867. 
Fibroid  and  allied  Degenerations,  No.  27,  Med.  Chir.  Review. 

H.  Josionck — On  Morbid  Histology.  Archiv  der  Heilkunde,  Bd.  xix.,  Heft  3,  p.  223, 
1878. 

Dr.  Kirkbride — On  Intemperance.  Report  for  1 87 1  of  Pennsylvania  Hospital  for  the 
Insane  on  Recoveries;   Report  for  1873,  of  2994  patients. 

Dr  Kiching — Lecture  on  Moral  Insanity   (British  Medical  Journal,  1857). 

Mr.  Lane — On  Treatment  of  Syphilitic  Insanity.  British  Medical  Journal,  October 
nth,  1873. 

Larrey — On  Insanity. 

Lavater — On  Physiognomy  of  Insanity. 

Dr.  Lawson — On  Pupils  in  General  Paralysis.  West  Riding  Medical  Reports,  vol.  vi. 
On  Perception  of  Pain  in  General  Paralytics.     Same  article. 

Dr.  Laycock — On  Insanity.     Nervous  Diseases  of  Women. 

Legrand,  du  Saulle — On  the  Insane  in  Paris,  during  1870-71.  Report  in  Annales, 
May,  1872,  p.  413,  of  case  of  Theodore,  a  case  of  Transitory  Mania;  On  Alcoholic  In- 
sanity.    Annales  Med.  Psych.,  October,  1859. 

Leidesdorf — On  Insanity  of  Gestation  or  Pregnancy.  Journal  of  Mental  Science,  Jan- 
uary, 1873. 

M.  Lelut — On  Pathology.  The  Value  of  Cerebral  Alteration,  in  Acute  Delirium  and 
Insanity,  1836. 

M.  Leuret — The  Moral  Treatment  of  Insanity. 

Leubuscher — On  Syphilitic  Insanity,  1861. 

Leyden — On  Disseminated  Sclerosis. 

Linnaeus  (1763) — On  Insanity. 

I^ombroso-^On  Insanity. 

Louis — On  Insanity  subsequent  to  Fever  (torn.  ii.). 

Dr.  J.  Luys — On  Mental  Diseases,  1881. 

Lucas,  P. — On  Heredity  (De  I'Hereditej. 

Lugony,  Dr. — On  Cretinism. 

Lunier — On  Intemperance.  Annales  Medico-Pyschologiques  for  1872.  On  War,  in 
same  journal.  Number  of  Insane  in  France  ;  Annales  Med.  Psych.,  January,  1870.  On 
Cretinism,  1867-68. 

Loggia,  Prof.,  of  Italy — Progressive  Paralysis  of  the  Insane.  Translated  by  Dr.  Nork- 
man,  in  No.  3,  vol.  iii.  of  Alienist  and  Neurologist. 

Dr.  A.  E.  MacDonald — General  Paresis.     Am.  Journal  of  Insanity,  April,  1877. 

Dr.  James  MacDonald — On  Puerperal  Insanity. 

Dr.  Macintosh — On  Opium  in  Insanity.     Article  in  Practice  of  Physic. 

Dr.  Magnan — Experimental  and  Clinical  Investigation  of  Alcoholism.  On  Hsemato- 
ma  Auris,  Annales  Medico-Psychologiques,  May,  1871. 

Dr.  Major — On  Causes  of  Insanity.  Journal  of  Psy.  Med.,  1877,  and  Wakefield  Asy- 
lum Report,  1877.  West  Riding  Asylum  Reports,  1874.  Histology  of  the  Morbid  Brain; 
On  Hypertrophy  of  Cells.     West  Riding  Asylum  Report,  vol.  iii.,  p.  109. 

Marc — On  Homicidal  Insanity  (vol.  i.,  p.  56);  On  Monomania  (vol.  i.,  p.  244);  On 
Uterine  Insanity  (vol.  i.,  p.  317) ;  On  Insanity,  op.  cit. 

Marce — Des  Maladies  Mentales,  1862. 

Marcet — On  Chronic  Alcoholic  Intoxication. 

Marshall— On  the  Brains  of  two  Idiots.     Phil.  Trans.,  1864,  p    526. 

Dr.  Macintosh — On  Hypodermic  Injection  of  Morphia,  paper  in  Journal  of  Mental 
Science  for  October,  1861. 

Mead — De  imperio  solio  et  lunae  in  corpore  Humana  et  Morbis. 

Dr.  Mason — On  Dipsomania. 

Mendel — On  Syphilitic  Insanity,  1868;  On  General  Paralysis  of  the  Insane. 

Meeson — On  Climacteric  Insanity.     (West  Riding  Medical  Reports,  vol.  vi.,  1876). 


688  APPENDIX   E. 

Meschede — Articles  on  General  Paralysis  in  Journal  of  ^Mental  Science ;  Pigmentary- 
Degeneration  of  Cells,  Virchow's  Archiv,  1865. 

Meyer — Syphilitic  Insanity,  1861. 

Miche — Treatise  on  Hypochondriasis ;   also  on  the  Blood  in  General  Paralysis. 

Dr.  Julius  Mickle — On  General  Paralysis,  Journal  of  Mental  Science,  April,  1878;  on 
Syphilitic  Insanity,  Brit,  and  For.  Med.-Chir.  Review,  July  and  October,  1876,  and  April, 

1877. 

Mierzejewski — On  Lesions  in  General  Paralysis,  Archiv  de  Physiologie,  1875. 

Mr.  Millard — A  Manual  for  the  classification,  etc.,  of  the  Feeble-minded';  Imbecile  and 
Idiotic  (Duncan  and  Mjllard,  1S66);  the  Idiot  and  his  helper,  Mr   Millard,  1864. 

Dr.  Hugh  Miller — On  Temporary  Kleptomania,  in  the  Lancet,  June  15,  1878. 

Dr.  W.  Julius  Mickle — General  Paralysis  of  the  Insane,  1880. 

Dr.  Minchin — On  Scalp  and  Cranium,  in  Dublin  Medical  Journal. 

Dr.  A.  Mitchell — On  Consanguineous  Marriages,  paper  in  Statistical  Society's  Jour- 
nal, June,  1875.  ^''^  Relapses,  contributions  to  the  Statistics  of  Insanity,  Journal  of 
Mental  Science  for  1877.  On  Idiots,  Journal  of  Mental  Science,  July,  1876.  Dipso- 
mania, same  Journal,  October,  1872. 

Monti,  Dr. — De  TOphthalmoscopie  dans  les  Maladies  Mentales,  ]Memoir  a  Pellagrous 
Insanity. 

Moreau — On  Hereditaiy  Transmission  (L'Union  Medicale,  No.  48). 

Mr.  Morell — Speculative  Philosophy  of  Europe  (Powers  of  the  Human  Mind), 

Morgagni — On  iklelancholia  (De  Sedibus  et  Causis  Morborum,  epist.  viii.). 

Nasse — On  Bodily  Causes  of  Insanity.  1836-39.  Moral  and  Physical  Causes,  Zeit- 
schrift  fiir  Psychiatric,  1S70;   on  Post-febrile  Insanity. 

Dr.  Needham — Statistics  (see  Tables  in  Report  of  York  Asylum  for  1873)  !  ^^  Homi- 
cidal Impulse,  Journal  of  Mental  Science,  July,  1872. 

Dr.  Noble — On  Opium,  23d  No.  of  Journal  of  >Iental  vScience. 

S.  W.  North — The  Legal  Doctrine  of  Responsibility  in  Relation  to  Insanity  (Trans- 
actions of  the  Social  Science  Association,  1864). 

Obeisteiner — On  Morbid  Histology.  Wien  Stzb.  d.  k.  Akad.  Wissener,  Bd.  Ixi.,  I  Abth., 
January,  1S71. 

Dr.  Orange — On  Epilepsy.     Report  of  Broadmoor,  1877. 

Dr.  Ordroneaux — Moral  Insanity.     Am.  Journal  of  Insanity,  January,  1873. 

Sir  James  Paget — Cerebral  Atrophy.  Lectures  on  Pathology.  Senile  Gangrene,  see 
same  work,  p.  463. 

Parcheppe — On  Insanity. 

Paulus  ^Egineta — On  Lycanthropia. 

Dr.  Peacock — On  Idiocy,  Pathological  Society's  Reports,  1858-59.  Notes  on  Pellagra, 
Brit,  and  For.  Medico-Chir.  Review,  January,  1863, 

Peddie,  Dr.— On  Dipsomania. 

Parrish,  Dr. — On  Dipsomania.     Treatise. 

Dr.  Pedler — On  Puerperal  Mania,   Medical  Reports,  1872,  vol.  ii. 

Dr.  Perfect — Annals  of  Insanity. 

Poincare — Pigmentary  Changes  in  Ganglia  of  Sympathetic. 

Pommerol's  Recherches  sur  la  Synostose  des  Os  du  Crane,  Paris,  1869. 

Portal — On  Mental  Diseases. 

Dr.  Prichard — Treatise  on  Insanity;  also  on  the  different  forms  of  Insanity, 

Ramaer — On  the  Bloodvessels  in  Insanity. 

Rav,  Dr. — On  the  Prognosis  of  Insanity  (Am.  Journal  of  the  Med.  Sciences,  October, 
1870)', 

Ripping — Die  Geistesstorungen  der  Schwangeren,  Wochnerinnen  n.  Saugenden,  1877. 

Dr.  Lockhart  Robinson — Essay  on  the  Moral  Management  of  the  Insane,  etc.  On 
Suicide,  Report  for  1862.  On  Treatment,  paper  in  Brit.  Med.  Journal,  October  3d,  1863, 
and  in  Journal  of  Mental  Science,  No.  48,  p.  547. 

Rokitansky — Pathology  of  Insanity. 

Romberg — Nervous  Diseases.     Article  on  Mania  and  Melancholia. 

Roussel— De  la  Pellagra,  Paris,  1862. 

Rutherford — Pathology  of  Insanity. 

Rush— Medical  Inquiries,  etc. 

Saleno — Report  of  Asylum  of  San  Serrola,  Venice. 

Salvatori  of  Moscow — On  Dipsomania,  in  Coinment.  Soc.  Phys.  Med.  apud  Univ. 
Mosquens  Instit.,  1807,  vol.  ii.,part  i.,  pp.  260-290. 

Sauder — On  Idiocy.     Archiv  fiir  P.sychiatrie,  1868, 


LITERATURE    OF    DISEASES    OF   THE    MIND.  689 

Dr.  Sankey — On  General  Paralysis,  and  Lectures,  1866. 

Dr.  Saunders — On   Chloral.     Report. 

Dr.  Savage— Hereditary  Predisposition,  Guy's  Hospital  Reports,  1877;  on  Klepto- 
mania,- Consideration  on  the  Cures  of  Insanity,  pp.  29,  30;  on  Insanity  with  Paralysis, 
Journal  of  Mental  Science,  January,  1878;   Chloral,  Journal  of  Mental  Science. 

Dr.  Schule — Hirn-Syphilis  und  Dementia  Paralytica. 

Seguin — The  Moral  Treatment,  Hygiene  and  Education  of  Idiots,  1846;  New  Facts 
and  Remarks  concerning  Idiocy,  1870. 

Seymour,  Dr. — Opiate  Treatment.     Medical  Gazette. 

Lord  Shaftesbury — On  Intemperance  and  Lunacy. 

Dr.  T.  Claye  Shaw — Journal  of  Mental  Science,  July,  1876.     On  Idiocy. 

Dr.  Sibson — Temporary  Insanity,  with  Taciturn  Melancholy  and  Hallucinations. 
Reynolds's  System  of  Medicine,  p.  286. 

Sir  J.  Simpson — On  Puerperal  Insanity. 

Dr.  Skae — On  the  Classification  of  the  Various  Forms  of  Insanity,  1863. 

Solly — On  the  Brain. 

Dr.  Julius  Steinan — On   Hereditary  Diseases. 

Dr.  Edward  C.  Spitzka — A  Contribution  to  the  Question  of  the  Mental  Status  of  Gui- 
teau,  and  the  History  of  his  Trial.  Alienist  and  Neurologist,  vol.  iv.,  No.  2,  and  other 
monographs. 

Sepelli  and  Marogliam — Studies  on  Cerebral  Thermometry  in  the  Insane  (in  this  re- 
lation see  work  of  Albes  of  Bonn,  1861). 

Dr.  H.  Sutherland— Menstrual  Irregularities,  in  West  Riding  Asylum  Medical  Reports, 
vol.  ii.,  1872. 

Sydenham — Articles  on   Hypochondriasis,  Suicides,  Febrile  Insanity,  Gouty  Insanity. 

Thierri — On  Pellagrous  Insanity.     Paris,  1775. 

Dr.  G.  Thompson — On  Pulse  Tracings  in  Gesieral  Paralysis,  vol.  i.  of  Reports  of  the 
Wakefield  Asylum;  in  Epileptic  Insanity,  West  Riding   Reports,  vol.  ii. 

Mr.  J.  B.  Thompson^ — Crime  and  Insanity.  The  Hereditary  Nature  of  Crime,  in 
Journal  of  Mental  Science,  January,  1870,  and  a  succeeding  paper  in  October  number 
on  same  subject. 

MM.  Thore  and  Aubanel — Statistics  of  the  Bicetre. 

Dr.  Thorne — On  Mental  Automatism.     St.  Bartholomew's  Hospital,  1870. 

Dr.  Thurnam — Statistics  of  Insanity. 

Dr.  Tilt — Diseases  of  Women.  Article  on  Climacteric  Insanity,  and  Remarks  on 
Kleptomania. 

Dr.  D.  Hack  Tuke — Manual  of  Psychological  Medicine.     Bucknill  and  Tuke.. 

Dr.  Batty  Tuke-— Histology  of  Insanity.      Manual  of  Psychological   Medicine. 

Dr.  T.  Harrington  Tuke — Oq  General  Paralysis,  466,  467,  468.  Bucknill  and  Tuke 
on  Forced  Alimentation,  745,  same  edition. 

Virchow — Cellular  Pathology. 

Vogel  (1764) — On  Mania,  Melancholia,  and  Amentia. 

Westphal — Articles  on  General  Paralysis,  in  Journal  of  Mental  Science,  Nos.  66  and 
68;  on  Syphilitic  Insanity.      1864. 

Dr.  Wigan— On  the  Duality  of  Mind. 

Dr.  Wille — On  Syphilitic  Insanity.      Report  of  Rheinan  Asylum,  near  Zurich. 

Die  Syphilitschen  Psychosen.     Allgemeine  Zeitschrift  fiir  Psychiatric,  1872,  p.  503. 

Dr.  Duckworth  Williams — On  Treatment,  No.  56  Journal  of  Mental  Science;  Journal 
of  Mental  Science,  April,  1873.     Also  No.  51  of  savne  journal. 

Dr.  L.  S.  Forbes  Winslow — Journal  of  Psychological  Medicine.     Articles. 

Dr.  Wolff — On  the  Pulse  in  the  Insane.  Allgemeine  Zeitschrift  fiir  Psyc-hiatrie, 
1867-9. 

Dr.  Wright — Report  of  Royal  Edinburgh  Asylum  for  187 1.     Insanity  from  Abdominal 
Disorders. 
.  Dr.  Yellowlees — Homicidal  Insanity.      Edinburgh  Medical  Journal,  1862. 

Bechterew  and  Heboid — Temperature  in  Insanity.  Archiv  iiir  Psychiatric,  Band 
xiii. 

Dr.  R.  W.  D.  Cameron — On  Restraint.     Journal  of  Mental  Science,  January,  1883. 

Dr.  Savage — Moral  Insanity.     Journal  of  Mental  Science,  1881-2. 

The  following,  which  does  not  claim  to  be  complete,  comprises  some  of  the  more  im- 
portant pamphlet  literature  which  has  appeared  during  the  past  few  years  in  this  country. 

44 


690 


APPENDIX    E. 


For  the  remainder,  the  reader  is  referred  to  the  American  Journal  of  Insanity,  the  Alienist 
and  Neurologist,  and  the  Journal  of  Mental  and  Nervous  Diseases. 

Dr.  E.  H.  Van  Deusen — Paper  in  the  American  Journal  of  Insanity  for  April,  1869, 
on  Nervous  Prostration,  Neurasthenia. 

Importance  of  a  Knowledge  of  Insanity  by  the  General  Practitioner  of  Medicine,  and 
General  Paresis.  Papers  by  Ira  Russell,  M.D.,  before  Worcester  North  District  Medical 
Society. 

Emotional  Insanity.     Paper  by  J.  K.   Bauduy. 

The  Structure  of  the  Vessels  of  the  Nerve-centres  in  Health,  and  their  Changes  in 
Disease.     American  Journal  of  Insanity  for  July,  1877,  and  January,  1S79. 

The  Problems  in  Insanity.  Paper  by  the  late  Dr.  George  M.  Beard,  read  before  the 
Medico-Legal  Society,  j\Iarch  3d. 

The  Simulation  of  Insanity  by  the  Insane,  Dr.  C.  H.  Hughes. 

The  Rights  of  the  Insane,  Dr.  C.  H.  Hughes. 

The  Special  Therapeutic  Value  of  Hyoscyamine  in  Psychiatry,  Dr.  C.  H.  Hughes. 

Acute  Dementia  occurring  in  an  Old  ^lan,  etc.,  Dr.  C.  H.  Hughes. 

On  the  Essential  Psychic  Signs  of  Neurasthenia,  Dr.  C.  H.  Hughes. 

The  Therapeutic  Value  of  Cephalic  and  Spinal  Electrization,  Dr.  Charles  H.  Hughes, 
and  other  various  valuable  articles  on  psychiatric  subjects. 

The  American  Journal  of  Neurology  and  Psychiatry.     McBride,  Gray,  and  Spitzka. 

Dr.  Edward  C.  Spitzka — The  Somatic  Etiology  of  Insanity,  Evidences  of  Insanity 
discoverable  in  the  Brains  of  Criminals,  etc..  Insane  Delusions,  and  other  papers. 

Prof.  C.  K.  Mills — Cerebral  Localization,  chiefly  with  Reference  to  Idiocy.  Paper 
before  the  Association  of  Medical  Ofificers  of  American  Institutions  for  Idiotic  and  Feeble- 
minded Persons,  October,  1882. 

Dr.  Workman — -Moral  Insanity,  what  is  it  ?  Canadian  Practitioner,  January  and  Feb- 
ruary, 1883. 

Dr.  W.  A.  Hammond — The  Influence  of  Age  upon  the  Mind  and  Body  in  relation  to 
Mental  Derangement.     Alienist  and  Neurologist,  April,  1883. 

Dr.  J.  G.  Kiernan — Folic  a  Deux,  its  Forensic  Aspects.  Alienist  and  Neurologist, 
Katatonia,  etc.,  etc. 

Dr.  Godding — Two  Hard  Cases. 

Dr.  Turnbull— ^On  Sphygmograms  in  Progressive  Paresis.  Boston  Medical  and  Sur- 
gical Journal,  ^lay  20,  1882. 

Allan  McLane  Hamilton — On  the  Case  of  Guiteau,  Boston  Medical  and  Surgical 
Journal,  March  9th,  1882;  Syphilitic  Hypochondriasis,  vol.  i.,  No.  i,  Alienist  and  Neur- 
ologist. 

Dr.  Folsom — Article  on  Guiteau.  Boston  Medical  and  Surgical  Journal,  February  9th, 
1882. 

Dr.  George  M.  Beard — The  Guiteau  Case.     1882. 

Dr.  Nathan  Allen — Insanity  in  Relation  to  the  Medical  Profession  and  Lunatic  Asy- 
lums. Paper  before  American  Association  for  the  Protection  of  the  Insane,  etc.,  1882, 
and  numerous  other  papers  on  kindred  subjects. 

Dr.  E.  C.  Seguin — Insane  Asylums  of  Spain,  Journal  of  Nervous  and  Mental  Dis- 
eases, July,  1883;  The  Function  of  a  Consulting  Staff"  to  Lunatic  Asylums,  paper  be- 
fore National  Association  for  the  Protection  of  the  Insane  and  the  Prevention  of  Insanity, 
and  other  papers  of  interest,    1882. 

Dr.  J.  C.  Shaw — On  Restraint,  etc.,  paper  before  National  Association  for  the  Protec- 
tion of  the  Insane,  etc.     1882.     On  Hyoscyamine,  paper. 

Dr.  C.  L.  Dana — The  Asylum  Superintendents  on  the  Needs  of  the  Insane ;  Statistics 
of  Insanity  in  the  United  States,  etc.  Paper  before  National  Association  for  the  Pro- 
tection of  the  Insane,  etc.,  1882  ;   and  other  papers. 

The  American  Psychological  Journal,  Dr.  Parrish. 

The  Medico-Legal  Journal  of  New  York. 

Isaac  N.  Kerlin — The  Epileptic  Change  and  its  Appearance  among  Feeble-Minded 
Children.  Paper  in  No.  3,  v(}l.  iii..  Alienist  and  Neurologist,  p.  329.  Also  Illustrations 
of  Juvenile  Insanity,  p.  348,  Alienist  and  Neurologist,  vol.  i.,  No.  3. 

Dr.  J.  Draper — Insanity  in  Great  Britain  and  upon  the  Continent  of  Europe.  Paper 
in  No.  3,  vol.  iii..  Alienist  and   Neurologist,  p.  375. 

Autopsy  of  Guiteau.  Official  report  of  Dr.  D.  S.  Lamb,  p.  468,  Alienist  and  Neurol- 
ogist, July,  1882. 


LITERATURE    OF    DISEASES    OF   THE    MIND.  69 1 

Illustrations  of  Juvenile  Insanity  ;  Morbid  Juvenile  Pyrophobia  caused  by  Malarial 
Toxaemia.     Willis  P.  King,  M.D.,  Alienist  and  Neurologist,  vol.  i..  No.  iii.,  p.  345. 

On  the  Propositions  of  the  Association  of  Medical  Superintendents  of  American  Hospi- 
tals for  the  Insane.     John  Curren,  M.D.,  Alienist  and  Neurologist,  vol.  i.,  Nos.  i,  2  and  3. 

Dr.  H.  P.  Stearns — Monograph  on  Insanity. 

Pliny  Earle,  M.D. — Subsequent  History  of  twenty-five  persons  reported  recovered 
from  insanity  in  1843,  vol.  i.,  No.  i,  Alienist  and  Neurologist.  Also  The  Curability  of 
Insanity  vs.  Recoveries  from  Mental  Diseases. 

Dr.  E.  M.  Nelson — Translation  in  vol.  i..  No.  I,  Alienist  and  Neurologist,  of  psychia- 
tric proceedings  of  the  Ii^ternational  Medical  Congress  at  Amsterdam. 

Dr.  J.  S.  Jewell — The  Influence  of  our  Present  Civilization  in  the  Production  of  Ner- 
vous and  Mental  Diseases.  Paper  in  vol.  vi.,  No.  i.  Journal  of  Nervous  and  Mental  Dis- 
eases, and  numerous  other  valuable  pajjers. 

Dr.  W.  J.  Morton — The  town  of  Gheel,  in  Belgium,  and  its  Insane,  etc.  Paper  in 
vol  vi..  No  I,  same  joarnal. 

Dr.  Dewey — Management  of  the  Insane.  Vol.  iii^  No.  i,  Journal  of  Nervous  and 
Mental  Diseases. 

Dr.  Clark  Gapen — Some  Exceptions  to  the  Present  Management  of  Plospitals  for  the 
Insane.     Vol.  iv.,  No.  3,  Journal  of  Nervous  and  Mental  Diseases. 

Dr.  J.  L.  Teed — Mind,  Insanity,  and  Criminality.  Vol.  v..  No.  I,  Journal  of  Nervous 
and  Mental  Diseases. 

Dr.  II.  M.  Bannister — Emotional  Insanity  in  its  Medico-Legal  Relation.  Vol.  v.,  No. 
I,  same  journal. 

Dr.  Landon  Carter  Gray — Cerebral  Thermometry.     Vol.  iv.,  No.  I,  same  journaL 

Reference  to  the  American  Journal  of  Insanity,  since  its  establishment,  will  reveal  to 
the  student  of  psychiatry  much  of  great  value  in  the  way  of  original  articles,  that  we 
have  not  time  to  tabulate,  but -which  compare  favorably  with  transatlantic  work  in  the 
same  field. 

With  respect  to  the  anatomy  and  physiology  of  the  nervous  system — the  pathology  of 
the  nervous  system  and  mind  and  pathological  anatomy — and  the  therapeutics  of  the  ner- 
vous system  and  mind,  the  student  will  be  amply  repaid  by  the  careful  perusal  of  the 
many  articles  contributed  to  these  departments  by  Drs.  Ray,  Kirkbride,  Earle,  Dr.  J.  S. 
Jewell,  Dr.  H.  M.  Bannister,  Dr.  Wm.  A.  Hammond,  Dr.  Meredith  Clymer,  Dr.  S.  Weir 
Mitchell,  Dr.  E.  vSeguin,  Dr.  Charles  H.  Hughes,  Dr.  Edward  C.  Spitzka,  Dr.  James  J. 
Putnam,  Dr.  Samuel  R.  Webber,  Professor  E.  T.  Mills,  Dr.  Amidon,  Dr.  A.J.  C.  Skene, 
Dr.  Landon  Carter  Gray,  Dr.  J.  C.  Shaw,  Dr.  J.  M.  Da  Costa,  Dr.  R.  Bartholow,  Dr. 
J.  Marion  Sims  and  others,  whose  indefatigable  labors  in  this  field  command  an  equal  re- 
spect with  those  of  Westphal,  Prof.  Erb,  Charcot,  Kifafft-Ebiag,  Hughliags  Jackson,  Wins- 
low,  and  Bucknill  and  Tuke  abroad.  ,    ■ 


PLATE  in. 


/^' 


'-Uit- 


.ym/^^^^^a^ 


(j/r^ 


Letter  written  by  a   pirson 


SUFFERING    FROM    AcUTE    MaNIA 


PLATE  IV. 


'Jjo  J- nnjxjuqxij 

Letier  written  by  an  Epileptic  with  Congicnitai.  Feeble  Intellect. 


INDEX. 


Abdominal  disorders,  insanity  from,  259 
Abstract  of  Lunacy  Laws  in  every  State  of 

the  Union,  see  Appendix,  631 
Active  hereditary  neurosis,  49,  54 
Acquittal  on  the  ground  of  insanity,  cases  of, 

90 
Acute  insanity,  pathology  of,  139 
Etiological  classilication,  47 
Etiology  of  insanity,  52,  53,  54,  55,  58 
Affective  insanity,  107 
Age,  influence  of,  55 
Ajax,  his  insanity,  37 
Alalia,  329 

Alcohol  as  a  cause  of  insanity,  56 
Alcoholic  insanity,  264 
Allbutt,  Dr.  Cliftbrd,  on  visceral  neuralgia, 

SH 

Alleged  increase  of  lunacy,  52 

Althaus,  Dr.,  on  electricity,  603 

American  asylums,  statistics  of,  163,  169, 
188,  193,  206 

Amidon,  335 

Amusements  for  the  insane,   187,  202,  218 

Ancient  classifications,  44 

Anaemia,  cerebral  and  spinafl,  490 

Anaesthesia,  331 

Anstie  on  insane  diathesis,  49;  on  neural- 
gia, 516;  on  electricity,  590 

Appendix,  631 

Arachnoid,  appearance  of,  in  insanity,  140, 
146 

Arnold,  trial  of,  121 

Arsenic,  chloro-phosphide,  251 

Arthritic  insanity  (see  Insanity  from  rheu- 
matism and  gout),  261 

Asylums,  care  and  treatment  in,  209,  216, 
217,  218 

Asymmetry  of  skull,  619 

Attendants,  209 

Austria,  laws  as  to  mental  responsibility  in, 
298 

Autopsies,  examination,  what  to  observe,  43 


B. 


Baillarger  on  paralytic  dementia,  103 
Bartholow,  Dr.  Roberts,  335 ;  on  electricity, 

548 
Bastian,  Dr.,  on  bloodvessels   in    insanity, 

141 


Baths,  245 

Bannister,  335 

Bayle  on  pathology  of  paralytic  dementia,  98 

Benedikt,  Dr.,  on  criminal  psychology,  120 

Blandlord,  Dr.,  on  diagnosis  of  moral  and 
emotional  insanity,  no;  on  bloodvessels, 
141  ;  on  treatment,  157,  282 

Blood,  examination  of,  144 

Bloodvessels  (cerebral)  in  insanity,  141,  151 

Brain  fatigue,  63 

Brain,  criminal,  formation,  626 

Brain,  normal  structure  of,  133;  changes  in 
insanity,  139 

Broadbent  on  cerebral  syphilis,  160,  315 

Bromide  of  sodium,  233,  238 

British  asylums,  statistics  of,  164 

Browne,  Dr.  Crichton,  treatment,  242 ;  on 
size  of  fcetal  head,  57  ;  on  optic  thalami, 
136;  on  admission  to  and  detention  in 
asylums,   177 

Bucknill  and  Tuke,  legal  tests  of  responsi- 
bility, 90;  hints  in  giving  evidence,  91  ; 
classifications,  38;  Bucknill's  definition, 
44;  Tuke's  classification,  49 ;  Bucknill's 
classification,  52 ;  on  diagnosis,  77 ;  on 
moral  or  emotional  insanity  proper,  107  ; 
Dr.  Bucknill  on  commitment,  detention 
and  discharge  of  patients,  178;  on  syphi- 
litic insanity,  263  ;  on  kleptomania  and 
pyromania,  265 

Buzzard,  Dr.  Thomas,  on  centric  galvaniza- 
tion, 587  ;  on  electrical  examination  and 
treatment  in  peripheral  paralysis  of  the 
facial  and  oculo-motor  nerves,  596 


Causes  of  cerebral  haemorrhage,  340 

Causes  of  insanity  (see  /Etiology),  52-58 

Calmeil  on  general  paralysis,  98  ;  on  epi- 
leptic insanity,  130 

Cambyses,  his  insanity,  37 

Camphor,  mono-bromide,  239 

Cannabis  indica,  233,  238 

Capacity,  testamentary,  70,  87 

Carpenter,  Dr.,  on  hereditary  transmission  of 
acquired  psychical  habits,  138 

Case  Book,  form  of  (see  Appendix  B). 

Cases  illustrating  treatment  of  insanity,  243, 

245. 
Cases  illustrating  pathology  and  morbid  his- 
tology of  insanity,  153 


694 


INDEX. 


Catamenia  in  prognosis  in  insanity,  75 

Catalepsy,  469 

Cells,  degeneration  of  cerebral,  147 

Cellular  pathology.  147 

Celsus,  his  classification,  38 

Cerebellum,  functions  of,   132;  lesions  of, 

jo7. 
Cerebral  and  spinal  anaemia,  490 
Cerebral  electrization,  61 
Cerebral  embolism,  339;  softening,  340,540 
Cerebral  haemorrhage,  localization  of  lesion, 

341 

Cerebral  hyperaemia,  537 

Cerebral  localization,  325 

Cerebral  syphilis,  63,317;  diagnosis  and 
prognosis  of,  317 

Cerebritis  or  encephalitis,  496 

Certificates  of  lunacy  (see  Appendix,  Ab- 
stract of  Laws),  176,  177,  178,  180,  181 

Change  of  character  in  insanity,  70,  78 

Charcot,  Dr.,  on  localization  of  brain  func- 
tion, 131  ;  on  locomotor  ataxia,  519;  on 
static  electricity,  554 

Charenton,  asylum  at,  281 

Chloral,  235 

Chemical  causes  of  ner\'ous  diseases,  34 

Chorea,  449 

Chronic  mania,  81 

Civil  incapacity,  86 

Civil  contracts,  87 

Civilization,  influence  of,  59  ;  foot-note,  55 

Clarke,  Dr.  Lockhart,  on  general  paralysis, 
100 

Classification  of  mental  diseases,  40;  Forbes 
Winslow  on,  285 

Climacteric  insanity,  258 

Clinical  instruction  in  hospitals,  218 

Clouston,  Dr.,  on  tubercular  insanity,  142  ;. 
on  epilepsy,  425 

Coke,  his  definition  of  idiocy,  105 

Colloid  degeneration  in  insanity,  150 

Colon,  insanity  proceeding  from,  259 

Codification  of  the  common  law  as  to  in- 
sanity, 303 

Commissioners  in  lunacy,  necessity  for  State 
boards,  296 

Combe's  definition  of  insanity,  44 

Concealed  insanity,  86 

Congenital  idiocy,  106 

Congenital  moral  defect,  85 

Congestion,  cerebral,  537 

Contractions,  330 

Conium,  240 

Commitment,  discharge  and  detention  of  the 
insane,  175 

Conolly,  Dr.,  his  definition  of  insanity,  44; 
his  abolishment  of  restraint,  277 

Corpora  quadrigemina,  functions  of,  135 

Consanguineous  marriages,  56 

Cortex  of  the  brain,  lesions  of,  132,  133 

Corpus  striatum,  lesions  of,  132;  functions 
of,   137 

Cottage  treatment  of  the  chronic  insane,  271 


Cowles,  Dr.  Edw^ard,  on  management  of 
hospitals,   208 

Cranial  nerves,  exit  of,  502 

Cranium,  43 

Cretinism,  38,  42 

Crichton  royal  institution,  54 

Criminal  lunatics,  189;  their  characteristic 
mental  peculiarities,  190,  625 

Criminal  skull  formation  (criminal  psy- 
chology), 618 

Crime  and  insanity,  618 

Crura  cerebri,  lesions  of,  132 

Curability  of  insanity,  162,  207,  208 

Curable  forms  of  insanity,  39,  75 


Da  Costa  on  vertigo,  465 

David,  37 

Definitions  of  insanity,  43,  44 

Delinquency  often  the  result  of  cerebral  im- 
perfection, 109,  618 

Delusions  of  the  insane,  69,  96,  243,  245 

Demeanor  towards  a  patient,  158 

Dementia:  primary,  106;  secondary,  106; 
diagnosis,  71,  80 

Dementia  paralytica  (see  General  paralysis), 

95  ... 

Deuteropathic  insanity,  50 

Development  of  the  nervous  system  by  evo- 
lution, 319 
Diagnosis,  pathology,  and  treatment  of  nerv- 
ous diseases,  322 
Diagnosis  of  insanity,  67  ;  in  criminal  cases, 
123 
mania,  70,  79 
melancholia,  71,  79 
dementia,  71,  80 
monomania,  83 
eccentricity,  82 
general  paralysis,  72, 79,  80,  85 
feigned  insanity,  85 
concealed  insanity,  86 
recovery,  72,  74 
incomplete  mania,  81 
chronic  mania,  81 
incomplete  primary  mania,  81 
moral    or    emotional    insanity 

proper,  72,  84 
congenital  moral  defect,  85 
moral  imbecility,  85 
Diagnostic  value  of  hereditary  tendency,  78 
previous  attacks,  78 
change  of  habit  and  dis- 
position, 78 
peculiarities  of  residence 
and  dress,  79 
Diathesis,  insane,  49 

Differential  diagnosis  betvv'een  syphilitic  in- 
sanity and  paralytic  dementia,  263 
Digitalis,  240 


INDEX. 


69s 


Dipsomania,  relations  to  insanity,  nature, 
pathology,  treatment,  354;  premature 
mental  decay  in,  363 ;  diagnosis  of,  354 ; 
psychic  symptoms  of,  364 ;  responsibility, 
368 
Dissection  of  bodies  of  the  insane,  43 
Disseminated  or  partial  sclerosis  in  insanity, 

I49>  542 
Domestic  treatment  of  the  insane,  224 
Donn,  Dr.,  on  idiocy,  106 
Dress,  peculiarities  of,  79 
Dura  mater,  appearance  of,  in  insanity,  140, 

146 


Eads,  Dr.,  335 

Earle,  Dr.  Pliny,  on  curability  of  insanity, 
162;  opium,  163 

Earl  of  Shaftesbury  on  the  admission,  de- 
tention, and  discharge  of  insane,  182 

Early  treatment,  importance  of,  157,  160, 
203 

Eccentricity,  diagnosis  of,  82 

Education  in  its  relations  to  insanity,  66 

Edinburgh  asylum  (Morningside),  279 

Electricity  in  neuralgia,  509 

Electricity  in  the  diseases  of  the  nervous 
system,  546 

Ekker  on  vessels  of  brain  in  insanity,  141 

Emotional  insanity,  47 

England,  insanity  in,  275 

Epilepsy  :  cause,  pathology,  treatment,  417, 
562 ;  cases,  422  ;  effect  on  mind,  256,  305 

Epileptic  insanity,  129,  256;  case  of  homi- 
cide, with  epileptiform  attack,  128;  un- 
conscious states  in,  256,  305 

Epithelium  in  insanity,  147 

Ergot  (fl.  ext.)  in  insanity,  241 

Erlenmeyer,  145  ;  on  paralytic  dementia,  99 

Ertzbischoff,  Dr.,  on  pathology  of  paralytic 
dementia,  99 

Erotomania  (nymphomania),  257 

Esquirol,  his  classification,  45  ;  his  improve- 
ments, 215  ;  on  epileptics,  306 

Etiology  (see  ^Etiology),  52-58 

Evidence,  hints  in  giving,  91 

Evidence  of  those  mentally  diseased,  88 

Examination  of  cases,  study,  43 

Examination  of  the  insane,  68,  81,  2S6 

Exciting  causes  of  insanity,  55 

Excitement  in  relation  to  recovery,  74 

Expert  testimony,  necessity  for  a  new  method 
of  introduction  of,  296 

Expert  testimony  and  the  functions  of  ex- 
perts, 92,  304 


P. 


Falret  on  epileptic  vertigo,  129;  on  para- 
lytic dementia,  103 
Fear  and  fright  as  causes  of  insanity,  49 
Feigned  insanity,  diagnosis  of,  85 


Ferrier,  Dr.  David,  on  lesions  of  the  Con- 
volutions of  the  brain  and  cortex  cerebri, 
349;  on  localization,  131 ;  on  optic  thala- 
mi,  136 

Fever  as  a  cause  of  insanity  (see  Post-feb- 
rile insanity),  260 

Flint,  Dr.  Austin,  on  neuralgia,  505 

Folic  raisonnante,  107 

Fournier  on  cerebral  syphilis,  319 

Food  and  work  and  amusement  for  the  in- 
sane, 218 

Frerichs  on  pathology  of  paralytic  demen- 
tia, 99 

France,  insanity  in,  281 ;  law  as  to  mental 
responsibility  in,  298 

Full  feeding  for  the  insane,  234 


G. 


Galvanization  of  sympathetic,  554 

Galen,  45 

General  practitioner's  duty  in  checking  in- 
sanity, 65,  foot  note 

General  paralysis  of  the  insane,  95,  255  ; 
cause,  95  ;  psychology  of,  95  ;  mental 
processes  in,  95  ;  prognosis,  95  ;  tempera- 
ture, pathology,  97 

General  sclerosis,  149 

Gestation,  insanity  of,  50,  257 

Gesture,  peculiarities  of,  70 

Gheel,  lunatic's  colony  at,  221 

Gouty  insanity,  261 

Gray  matter  of  brain,  morbid  histology  of, 
in  insanity,  149 

Gray,  Dr.  John  P.,  on  curability  and  treat- 
ment, 169;  on  commitment,  detention, 
and  discharge,  175  ;  on  restraint  and  se- 
clusion, 172 

Grief  as  a  cause  of  insanity,  57 

Griesinger  on  classification,  47 

Guislain,  his  definition,  44 


H. 

Hamilton,  335 

Hsemorrhage,  cerebral,  340 

Hallucinations  of  the  senses,  68 

Hammond,  335 

Handwriting  and  composition  of  the  in- 
sane (see  Appendix) 

Hartford  retreat  for  insane,  206 

Hardness  of  feeling  exhibited  by  the  insane 
towards  friends,  69,  foot  note 

Head  and  spine,  affections  of,  as  causes  of 
mental  disease,  56 

Hebephremia,  or  pubescent  insanity,  50,  257 

Headache  (see  Neuralgia) 

Hemiplegia,  329 

Hereditary  insanity,  54 ;  predisposition  as 
a  cause,  54;  affecting  diagnosis,  progno- 
sis, treatment,  54 


696 


INDEX. 


Hereditary  transmission,  56;  of  allied  but 
different  neuroses,  56 

Hints  in  giving  evidence,  91 

Histology  and  functions  of  cerebrum,  131 

Histology  (morbid)  of  mental  diseases,  139 

Hippocrates,  writings,  38 

Homicidal  insanity,  130,  183,  301 

Hospital  wards,  necessity  for,  in  asylums  for 
the  insane,  187 

Hospitals  for  the  insane,  69,  foot-note ; 
208,  216,  226,  272 

Hughes,  Dr.  Chas.  H.,  on  moral  or  emo- 
tional insanity  proper,  III 

Hyoscyamus,  237 

Hyperaemia  (cerebral),  537 

Hypochondriacal  melancholia,  260 

Hystero-epilepsy,  442 

Hysteria,  history,  pathology,  and  treatment, 
376 

Hypersesthesia,  331;  of  testes,  552;  of 
uterus,    552 

Hysterical  insanity,  257 

Hypothetical  cases,  93 


I. 


Ideational  or  intellectual  states,  49 

Idiocy,  105;  classification  of,  106;  prog- 
nosis, 105  ;  definition,  105  ;  treatment,  105 

Idiopathic  or  primary  insanity,  42,  48 

111  health  as  a  cause  of  insanity,  60 

Impulsive  insanity,  127 

Importance  of  early  recognition  of  mental 
disease,  59 

Impatience  in  relation  to  recovery,  72,  74 

Imbecility,  42 

Increase  of  insanity,  266 

Inebriety,  its  cause,  pathology  and  treat- 
ment, 354;  its  seat,  359 

Indian  hemp  (see  Cannabis  indica),  233—238 

Inflammatory  disease  of  the  brain  and  its 
membranes,  496 

Inflammation  and  congestion  of  the  brain 
tissue  in  mental  disease,  1 00 

Incurable  forms  of  insanity,  40 

Insanity  in  general,  37;  clinical  view  of, 
354 

Insanity  in  the  Middle  States,  266 

Insane,  their  condition  before  the  era  of 
hospitals,  161,  216;  abstract  of  the  com- 
mon law  on  their  confinement  in  different 
States  of  the  Union  (see  Abstract  in  Ap- 
pendix) ;  can  distinguish  between  right 
and  wrong,  300  ;  some  apparently  recover 
and  deny  they  have  ever  been  insane, 
and  are  bitter  towards  all  who  treated 
them  as  insane,  255 

Insanity  of  pubescence,  257  ;  from  mastur- 
bation, 257;  of  gestation  and  pregnancy, 
257;  of  lactation,  258;  from  abdominal 
disorder,  259 


Insanity,  its  connection  with  organic  qual- 
ities of  the  brain  overlooked,  252;  dis- 
tinguished   from     depravity,  255  ;   remis- 
sion in  the  early  stage,  73,  74 
Influence  of  the  seasons  on  insanity,  59 
Intemperance  as  a  cause  of  insanity,  56 
International  congress    of    alienists,   their 

classification,  38 
Injuries  to  the  back  without  apparent  me- 
chanical lesion,  614 
Irresistible  impulse,  122,  303 
Irritative  lesion  of  the  brain,  353 


Jackson,  Dr.  Hughlings,  chorea,  451;  ex- 
perimental researches,  354  ;  on  epilepsy, 
129,  420 

Jewell,  335 

Judges  should  not  assume  the  functions  of 
experts,  93 

Juvenal,  his  mention  of  hellebore,  37 


Kirkbride,  Dr.  Thomas,  statistics,  etc.,  asy- 
lum, 193 ;  on  prompt  treatment,  203 ; 
management  and  curability  of  mental  dis- 
eases, 203 

Klein,  Dr.,  on  ophthalmoscopic  appearance, 
144 

Kleptomania,  118,  265,  306,  474;  Mare, 
Browne,  Savage,  Ray,  Tilt,  etc.,  on,  as  a 
state  of  undoubted  insanity,  265 

Kolk,  Van  der,  427 

Krafft-Ebing,  Dr.,  his  classification,  40,  42 

Kussmaul  and  Tenner,  experiments  on  ep- 
ilepsy, 432 


L. 


Lactation,  insanity  of,  48,  258 

Lancereaux  on  pathology  of  paralytic  de- 
mentia, 98 

Larceny  in  general  paralysis,  306 

Laycock's  physiological  classification,  46 

Laros  case,  478 

Legal  enactments  in  reference  to  insanity 
(see  Appendix) 

Legal  tests  of  responsibility,  90 

Lesions  of  the  brain,  337,  349  ;  pons,  332; 
crus  cerebri,  3^3 '■■  optic  thalamus,  334; 
of  hemispheres,  335  ;  of  cerebellum,  337  ; 
of  motor  zone,  350  ;  of  sensory  zone,  352 

Lightning,  case  of  stroke,  and  markings  by, 
607 

Localization  of  chronic  lesions  of  nerve- 
centres,  329,   331 

Localization  of  brain  functions,  131 

Locomotor  ataxia,  nature  and  pathology, 
518;  Radcliff  on,  525 


INDEX. 


697 


Longevity  of  the  insane,  161 

Lord     Moncrief    of  Scotland,    on  lunatics, 

303 
Lord  Justice  Blacl<;burn  on  homicide,  303 
Lord  Chief  Justice  of  England  on  responsi- 
bility,_  303 
Lunacy  in  England,  275 
Lunacy  laws,  see  Abstract  of,  in  Appendix, 

631 
Lunatics,  laws  relating  to  (Appendix),  631 
Lunacy,  English  commissioners  of,  232 
Luys,  on  pathology  of  paralytic  dementia, 

99        . 
Lungs,  disease  of,  in  insanity,  261 
Lunier,  on  intemperance  as  a  cause  of  in- 
sanity, 56;  paralytic  dementia,  103 
Lypemania,  45 


M. 

Magnan  on  general  paralysis,  98 

Major,  Dr.,  on  brain  wasting,  141 ;  on  de- 
generation of  brain  cells,  148 

Management  of  property  of  the  insane,  89 

Management  of  hospitals  for  the  insane, 
209,  216,  218,  224,  226 

Mania,  diagnosis  of,  71,  81  ;  treatment  of, 
254;  acute,  254;  chronic,  81  ;  transitory, 
130 

Mare  on  pyromania,  265 

Marce  on  epilepsy  with  transitory  mania, 
130 

Marriage,  iniluence  of,  56,  foot-note ;  mar- 
riage contracts,  87  ;  its  impropriety  when 
insanity  is  in  the  family,  56 

Marriages  of  consanguinity,  56,  foot-note 

Masked  epilepsy,  129,  130 

Masturbatic  insanity,  257 

Mauriac,  Dr.  Charles,  on  syphilis  of  nervous 
centres,  317 

Maudsley,  Dr.  Henry,  on  treatment,  224 ; 
classification,  47  ;  on  commitment,  de- 
tention and  discharge,  181 

McLean  Asylum,  Somerville,  Mass.,  207 

Medico-legal  importance  of  epileptic  at- 
tacks, 477 

Mendacity  of  the  insane,  49 

Menstrual  periods  accompanied  by  increase 
of  excitement,  61 

Mechanical  restraint  and  seclusion,  223 

Medulla  oblongata,  lesions  of,  132 

Medical  certificates  of  lunacy  (see  Abstract 
of  laws  in  Appendix),  631 

Medicinal  treatment  of  mental  disease,  233 

Mental  responsibility  in  criminal  cases,  119, 
129,  297,  307 

Melancholia,  diagnosis  of,  71,  79;  treat- 
ment of,  254;  suicidal  melancholia,  235, 
250 

Membranes,  morbid  histology  of,  146 

Mechanical  cause  of  nervous  diseases,  34 

Menstruation  (see  Catamenia),  75 


Menstrual  psychoses,  61 
Meynert  on  optic  thalami,  136 
Metaphysical  theory  of  insanity,  39 
Methomania     (see     Dipsomania     and    In- 
ebriety), 353 
Miche  on  the  blood  in  general  paralysis, 

145 

Mickle  on  syphilitic  insanity,  262 

Miliary  sclerosis,  150 

Mills,  335 

Modern  classifications  of  insanity,  44 

Modern  nervousness  of  men,  66 

Monomania,  diagnosis  of,  83 

Modern  nervous  disease,  31 1 

Moral  causes  of  insanity,  105 

Monoplepia,  351 

Moral  imbecility,  108,  251;,  624 

Moral  insanity,  107;  synonyms,  107;  seti- 
ology,  diagnosis,  72 ;  nature,  107 ;  ad- 
mitted by  the  best  observers.  Dr.  Hiighes 
on,  III,  624 

Moral  treatment  of  the  insane,  209,  216, 
217 

Morbid  histology,  145  ;  of  acute  and  chronic 
insanity,  139 

Morel,  his  classification,  38;  definition,  44 

Motor  zone  of  brain,  349 

Motor  irritation,  330 

Music,  color,  beauty,  etc.,  as  curative  agents 
in  insanity,  15S 


N. 


Nature  of  brain  lesions,  338 

Nature,  her  efforts  to  restore  mental  equi- 
librium, 158 

Nebuchadnezzar,  insanity  of,  37 

Nerve  fibres  in  insanity,  148;  nerve-stretch- 
ing, 509    .    . 

Nerve-cells  in  insanity,  147 

Nervous  diseases  (modern),  disorders  of,  in 
general,  312 

Neurasthenia,  signs  of,  60 ;  motor  symp- 
toms of,  506 ;  physical  signs,  506 

Neuralgia,  501 

Neuralgia  of  brain  in  insanity,  149 

Nichols,  Dr.  Chas.,  opinions  on  treatment 
of  insanity,  and  statistics  of  insanity,  188 

Non  compos  mentis,  105 

Northamptom    Lunatic    Hospital    (Mass.), 

Nosology  of  insanity  (see  Classification),  40, 

44 
Nothnagel,  on  optic  thalami,  136 
Non-restraint,  172,  188,  224,  227 
Nymphomania,  257 


Occupation,  influence  of,  202,  219,  220 
Occupations,  particular,  219 


698 


INDEX. 


Occipital  flatness,  621 

Ophthalmoscope    in    mania,    melancholia, 

etc.,  143 
Ophthalmoscope  in  diagnosis,  323 
Opinions,  medical,  given  in  writing,  93,  94 
Opium  in  the  treatment  of  insanity,  234 
Optic  thalami,  functions  of,  135 
Oxaluria,  mania  of,  145,  foot-note 


Parish  will  case,  94 

Paralysis  from  brain  disease,  331 

Parchappe,  pathology,  139;  classification, 
46 

Partial  insanity,  81,  301,  303,  305,  308 

Parturition,  insanity  of,  258 

Paraplegia,  329 

Pathological  classification,  46 

Pathology  of  insanity,  139,  153 

Pathological  diagnosis  in  brain  diseases,  339 

Peculiarities  (see   Diagnosis),  79 

Pennsylvania  Lunatic  Hospital  at  Philadel- 
phia, statistics  of,  193 

Periodical  insanity,  243 

Persecution,  delusions  of,  258 

Phthisical  insanity,  142,  261 

Phthisis  in  insanity,  142  (also  see  chapter 
of  cas.es),  261 

Phy.4ognomy  in  insanity,  70,  71,  80 

Physiological  classification,  46 

Pia  mater,  changes  in  insanity,  140,  146 

Pinel's  and  Esquirol's  improvements,  215 

Pinel  on  classification,  38 

Pons  varolii,  hsemorrhage  into,  132 

Population,  proportion  of  insane  to  the,  162 

Poore,  Dr.,  on  electricity,  584 

Post-febrile  insanity,  260 

Provision  fv-r  the  chronic  insane,  271 

Pregnancy,  insanity  of,  257 

Previous  attacks,  78 

Prevention  of  insanity,  64 

Progressive  muscular  atrophy,  329 

Prodromic  stage  of  insanity,  302 

Proportion  of  sane  to  insane  at  home  and 
abroad,  162  266 

Premature  mental  decay  in  inebriety,  363  ; 
bram  changes,  366 

Prichard,  Dr.,  on  classification,  47 

Private  patients,  treatment  of,  224,  231 

Prognosis  of  insanity,  74-77,  287.  (Prob- 
ability of  recovery  in  any  given  case  is  in 
proportion  to  the  early  age, physical  con- 
dition and dui'ation  of  the  attack.) 

Progressive  general  paresis  (syn.  paralytic 
dementia),  95 

Protopathic  insanity,  50 

Prognosis  in  cerebral  hgemorrhage,  341 

Psychical  school  of  alienists,  47 

Psychological  classification,  47 

Psychology  of  crime,  617 

Pubescent  insanity  (hebephremia),  50,  257 


Puerperal  insanity,  258 
Pulse  in  insanity,  243 
Pupils  in  insanity,  243 
Purgatives  in  insanity,  233 
Pyromania,  118,  265 


Ramskill,  Dr.  J.  S.,  on  epilepsy,  439 

Ray,  Dr.,  on  insanity,  93,  no;  in  memo- 
riam  of,  271  ;  on  epilepsy,  305  ;  on 
restraint  and  seclusion,  226 ;  on  pyro- 
mania, 265 

Reasoning  mania  or  monomania,  107 

Recovery  often  confounded  with  improve- 
ment, 73 

Restraint,  true  doctrine  of,  Ray  on,  Nichols 
on,  226 

Rest  in  insanity,  158 

Recovery,  diagnosis  of,  72,  74 

Recurrent  mania,  243 

Regional  diagnosis  of  spinal  cord  and  brain 
lesions,  319 

Reform  in  the  method  of  introducing  expert 
evidence,  232,  296 

Religious  excitement  as  a  cause  of  insanity, 
260 

Removal  from  an  asylum,  72,  74 

Remission,  its  occurrence  in  the  early  stages 
of  insanity,  309 

Reproductive  organs,  diseases  of,  in  insan- 
ity, 257 

Reynolds,  Dr.  J.  Russell,  on  electricity,  556; 
on  epileptic  vertigo,  256;   on  chorea,  460 

Responsibility  of  inebriates,  363 ;  of  the 
insane,  302-309 

Rheumatic  insanity,  261 

Rindfleisch  on  disseminated  sclerosis,  150 

Ro'vitansky  on  pathology  of  paralytic  de- 
mentia, 99 

Rush,  270 


Sanity,  diagnosis  of  mania  from,  70 

Scalp  and  cranium,  43 

Sciatica,  503,  550 

Science,  changes  in  laws  should  keep  pro- 
gress with  the  advancement  of  cerebral 
pathology,  304 

Sclerosis,  421 

Sedatives  in  insanity,  2QI 

Secretions  (see  Examination  of  blood  and 
urine),  144 

Seguin,  335 

Self-control,  absence  of,  in  insanity,  300,  303 

Sensory  zone  of  brain,  352;  sensorial  irri- 
tation, 330 

Sex,  influence  of,  in  insanity,  55 

Sibbald,  civil  incapacity,  86 

Simulation  of  insanity  can  be  detected,  85  ; 
how  distinguished  from  real  insanity,  85 


INDEX. 


699 


Pkae,  Dr.,  his  classification,  47 

Skey,  Dr.  F.  C,  on  hysteria,  392 

Skin,  79 

Skull  formation  in  criminals,  618 

Sleep,  75 

Small  hospitals  for  the  insane,  Dr.  Cowles 
on,  208 

Somatic  school  of  alienists,  50 

Somato-setiological  classification,  48,  49 

Softening  of  brain,  540 

Somnambulism,  468 

Special  pathological  changes  in  insanity,  146 

Spencer,  Herbert,  on  the  emotions,  58 

Spinal  concussion,  its  medico-legal  rela- 
tions, 608 

Spinal  cord,  lesions  of,  331 

Spitzka,  335 

Statistics  of  different  asylums :  Blooming- 
dale,  188;  New  York  State,  169;  Penn- 
sylvania hospital,  193;  three  State  hos- 
pitals of  Massachusetts,  163;  etc.,  in 
general,  58 

States  of  unconsciousness,  466 

Stomach  and  intestines,  diseases  of,  in  in- 
sanity, 259 

Suicidal  insanity,  294 

Suspicion  a  common  trait  of  insanity,  262 

Sutherland,  Dr.,  on  the  urine  in  insanity,  145 

Sydenham,  Dr.,  on  hysteria,  381 

Sympathetic  insanity,  42 

Symptomatological  classification,  45 

Syphilitic  insanity,  159;  foot-note,  262 

Syphilitic  nervous  disease,  315,  317 


Tables  of  causes  often  unreliable,  57 

Temperament,  insane,  49 

Testimony,  skilled,  charged  with  being  con- 
tradictory, etc.,  92 

Testamentary  capacity,  70 

Tests  of  responsibility,  307 

Temperature  of  body  in  cerebral  hsemor- 
rhage,  340 

Therapeutics  of  insanity,  233 

Toxic  insanity,  50 

Trance  state,  126 

Transitory  mania,  122,  126 

Treatment  of  insanity,  157 

Treatment  of  inebriety,  361,  372 

Trembling,  330 

Treatment  of  cerebral  hsemorrhage,  343 


Trouble  and  grief  as  causes  of  insanity,  57 
Trousseau,  129 

Tubercular  disease  in  insanity,  261 
Tuke,    Dr.    J.    Batty,    his    histological    re- 
searches in  insanity,  145 
Types  of  insanity,  see  frontispiece 


Ulysses,  feigned  insanity,  37 
Unconsciousness,  states  of,  466 
Uncontrollable  impulse,  474,  475 
Unnatural  and  motiveless  crimes  diagnostic 

of  epilepsy,  305 
Urine  in  insanity,  144,   145 
Uterine  disorders  as  a  cause  of  insanity,  293 
Utero-mania,  257 


Varieties  of  insanity  in  relation  to  treat- 
ment, 252 

Vertigo,  nature  and  treatment  of,  462  ;  sta- 
tic, 330 

Vertex  steepness,  621 

Vital  causes  of  nervous  disease,  34 

Visceral  disease  in  insanity,  293 

Visceral  neuralgias,  504 

Voison,  Aug.,  on  general  paralysis,  102 


■w. 

Warm  baths,  prolonged,  in  insanity,  245,  290 

Webber,  335 

Weakness  of  mind   (see  Idiocy,  Dementia, 

and  Epilepsy) 
Westphal,  on  general  paralysis,  100 
Wills  of  the  insane,  87 
Winslow,  Dr.   Forbes,  on  insanity  and  its 

treatment,  283 ;  on  simple  classifications, 
■    285 
Winn,  Dr.,  on  correlation  of  morbific  forces, 

142 
Willis.,  case  of,  122 
Wille  on  syphilitic  insanity,  262 
Wilks  on  epilepsy,  435;  on  hysteria,  411  ; 

on  electricity,  579 
Work  in  the  treatment  of  insanity,  202,  219, 

220 


CATALOGUE  NO.  1. 


SEPTEMBER,  18S3, 


CATALOGUE 


EDicAL.  Dental,  Pharmaceutical 


AND 


SCIENTIFIC  PUBLICATIONS, 


PUBLISHED    BY 


P.  BLAKISTON,  SON  &  CO.. 

(SUCCESSORS    TO    LINDSAY   &    BLAKISTON) 

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ROBERTS'  PRACTICE  OF  MEDICINL 

A  New  Enlarged  Edition, 

JUST  READY. 

"Uniformly  commended  by  the  Profession  and  the  Press. 

A.  HAIS^D-BOOK  OF  THE  THEORY  AND  PRACTICE  OF  IMEDL 

•       CINE.     By  Frederick  T.  Roberts,  M.D.,  M.R.C.P.,  Assistant  Pro- 

.  fessor  and  Teacher  of  Clinical  Medicine  in  University  College  Hospital, 

Assistant  Physician  in  Brompton  Consumptive  Hospital,  &c.,  &c. 

Third  Edition.     Octavo.     Price,  in  cloth       ....       $5.00 

leather       ....         6.00 
The  Publishers  are  in  receipt  of  numerous  letters  from  Professors  in  the  various  Med- 
ical Schools,  uniformly  commending  this  book;  whilst  the  following  extracts  from  the 
Medical  Press,  both  English  and  American,  fully  attest  its  superiority  and  great  value 
not  only  to  the  student,  but  also  to  the  busy  practitioner. 

This  is  a  good  book,  yea,  a  very  good  book.  It  is  not  so  full  in  its  Pathology  as  "  Aitken," 
so  charming  in  its  composition  as  "  Watson,"  nor  so  decisive  in  its  treatment  as  "  Tanner ; " 
but  it  is  more  compendious  than  any  of  them,  and  therefore  more  useful.  We  know  of  no 
other  work  in  the  English  language,  or  in  any  other,  for  that  jnatter,  which  competes  with 
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We  have  much  pleasure  in  expresping  our  sense  of  the  author's  conscientious  anxiety  to 
make  his  work  a  faithful  representation  of  modern  medical  beliefs  and  practice.  In  this  he 
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ers: it  is  a  remarkable  evidence  of  industry,  experience,  and  research.  —  Practitioner. 

That  Dr.  Roberts's  book  is  admirably  fitted  to  sitpply  the  want  of  a  good  hand-book  of 
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Dr.  Eoberts  has  accomplished  his  task  in  a  satisfactoiy  manner,  and  has  produced  a  work 
mainly  intended  for  students  that  will  be  cordially  welcomed  by  them;  most  of  the  observa- 
tions on  treatment  are  carefully  written  and  worthy  of  attentive  study;  the  arrangement  is 
good,  and  the  style  clear  and  simple.  — London  Lancet. 

It  contains  a  vast  deal  of  capital  instruction  for  the  student,  much  valuable  matter  in  it  to 
commend,  and  merit  enough  to  insure  for  it  a  rapid  sale. — London  3Iedical  Times  and  Gazette. 

There  are  great  excellencies  in  this  book,  which  will  make  it  a  favorite  both  witli  the 
accurate  student  and  busy  practitioner.  The  author  has  had  ample  experience. — Richmond 
and  Louisville  Journal. 

W^e  confess  ourselves  most  favorably  impressed  with  this  work.  The  author  has  performed 
his  task  most  creditably,  and  we  cordially  recommend  the  book  to  otir  readers.  —  Canada 
3Iedical  and  Surgical  Journal. 

A  careful  reading  of  the  book  has  led  us  to  believe  that  the  author  has  written  a  work 
more  nearly  up  to  the  times  than  any  that  we  have  seen  ;  to  the  student,  it  will  be  a  gift  of 

priceless  value.  — Detroit  Review  of  Iledicine. 

Our  opinion  of  it  is  one  of  almost  unqualified  praise.  The  style  is  clear,  and  the  amount  of 
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It  is  of  a  much  higher  order  than  the  usual  compilations  and  abstracts  placed  in  the  hands 
of  students.  It  embraces  many  suggestions  and  hints  from  a  carefully  compiled  hospital 
experience ;  the  style  is  clear  and  concise,  and  the  plan  of  the  work  very  judicious. — Medical 
and  Surgical  Reporter. 

It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands  as  a  compendium  for  students 
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If  there  is  a  book  in  the  whole  of  medical  literature  in  which  so  much  is  said  in  so 
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BIBLE  HYGIENE; 

Or,  Health  Hints.  By  a  Physician.  This  book  has  been  written,  first,  to  im- 
part in  a  popular  and  condensed  form  the  elements  of  Hygiene  ;  second,  to  show 
how  varied  and  important  are  the  Health  Hints  contained  in  the  Bible,  and  third, 
to  prove  that  the  secondary  tendency  of  modern  Philosophy  runs  in  a  parallel 
direction  with  the  primary  light  of  the  Bible.     i2mo.       Paper,  .50;  Cloth,  $1.00 

■'  The  scientific  treatment  of  the  subject  is  quite  abreast  of  the  present  day,  and  is  so  clear  and  free  from  unne- 
cessary technicalities  that  readers  of  all  classes  may  peruse  it  with  satisfaction  and  advantage." — Edinburgh 
Medical  yournal. 

BIDDLE,  MATERIA  MEDICA.      Ninth    Edition. 

[Contains  all  the  changes  in  the  Sixth  Revision  of  the  New  Pharmacopoeia.^ 
Materia  Medica.  For  the  Use  of  Students  and  Physicians.  By  the  late 
Prof.  John  B.  Biddle,  m.d..  Professor  of  Materia  Medica  in  Jefferson  Medi- 
cal College,  Philadelphia.  The  Ninth  Edition,  thoroughly  revised,  and  in 
many  parts  rewritten,  by  his  son,  Clement  Biddle,  m.d..  Assistant  Surgeon, 
U.S.  Navy,  assisted  by  Henry  Morris,  m.d.  Containing  all  the  additions 
and  changes  made  in  the  last  revision  of  the  United  States  Pharmacopoeia. 
The  Botanical  portions  have  been  curtailed  or  left  out,  and  the  other  sections, 
on  the  Physiological  action  of  Drugs,  greatly  enlarged.     Octavo. 

Cloth,  M-oo;  Leather,  $4.75 


"  The  additions  are  valuable,  and  we  must  congrat- 
ulate the  author  upon  having  improved  what  was 
already  so  useful  a  work,  both  to  the  student  and  phy- 
sician."— Phi/a.  Medical  and  Surgical  Reporter. 

"  It  has  been  the  design  of  the  author  to  present  in 
his  work  a  text-book  for  the  student.  It  is  brief,  and 
yet  sufficiently  comprehensive.  His  style  is  clear  and 
yet  succinct.  He  covers  the  ground — covers  it  well, 
'and  cumbers  his  work  with  nothing  superfluous." — 
Atlanta  Medical  and  Surgi^:al  yournal.  !     Canada  Lancet. 


"  One  thing  that  particularly  recommends  this  work 
to  the  student  is,  that  the  book  is  not  so  large  as  to  dis- 
courage and  cause  him  to  fee!  that  it  is  impossible  for 
him  to  get  over  it  and  so  much  else  in  the  short  time 
before  him." — St.  Louis  Medical  and  Surgical  your- 
nal. 

"  It  contains,  in  a  condensed  form,  all  that  is  valu- 
able in  materia  medica,  and  furnishes  the  medica! 
student   with  a  complete  manual  on  this  subject." — 


p.  BLAKISTON,  SON  &-   CO:S 


BREWING,  DISTILLING,  ETC. 

The  Brewer,  Distiller  and  Wine  Manufacturer  ;  a  Handbook  for  all  interested 
in  the  Manufacture  and  Trade  of  Alcohol  and  its  Compounds.  Edited  by  John 
Gardner,  Fellow  of  the  Chemical  Society  of  London.    Illustrated.   Cloth,  $1.75 

Synopsis  of  Contents. — Alcohol,  its  Preparations,  etc. ;  Alcoholometry ; 
Brewing  and  Beers;  Varieties  of  Malt  Liquors;  Malt;  Raw  Grain;  Sugar; 
Hops;  Arrangement  of  a  Brewery;  Different  Processes;  Chemical  Changes 
during  Washing,  Boiling,  Cooling,  Fermentation,  etc.,  etc. ;  Storing  and  Clari- 
fying, Porters,  Ales  ;  Analysis  of  Beers,  Ciders,  Perry,  Mum  ;  Liquors  and  Cor- 
dials, giving  over  80  preparations.  Other  sources  of  Spirituous  Liquors  ;  Dis- 
tillation of  Alcoholic  Liquors,  including  Rums,  Brandies,  Whiskies,  Gins,  etc. ; 
Wine  and  Wine  Making  ;  Tests  for  Adulterations  ;  Remarks  on  the  Cultivation 
of  Grapes,  etc.;  Imitation  of  Wines. 

BLOXAM.  CHEMISTRY,Inorganic  and  Organic.     Fifth  Edition. 

■  With   Experiments.     By   Charles   L.  Bloxam,  Professor  of  Chemistry  in 
King's  College,  London,  and  in  the  Department  for  Artillery  Studies,  Wool- 
wich.    Fifth  edition.     With  nearly  300  Engravings.     Cloth,  ^4.00;  Leather,  $5.00 
A  most  complete  Text-Book  for  Schools  and  Colleges. 

"  Professor  Bloxam  has  given  us  a  most  excellent  and  useful  practical  treatise.  His  656  pages  (now  700)  are 
crowded  with  facts  and  experiments,  nearly  all  well  chosen,  and  many  quite  new,  even  to  scientific  men  .  .  . 
It  is  astonishing  how  much  information  he  often  conveys  in  a  few  paragraphs.  We  might  quote  fifty  instances  of 
this." — Chemical  I^eivs. 

BLOXAM,     LABORATORY  TEACHING.     Fourth  Edition. 

Progressive  Exercises  in  Practical  Chemistry.  By  Charles  L.  Bloxam, 
Professor  of  Chemistry  in  King's  College,  London,  etc.  Fourth  edition.  With 
89  engravings.     i2mo.  Price  ^1.75 

This  work  is  intended  for  use  in  the  Chemical  Laboratory,  by  those  who  are 
commencing  the  study  of  Practical  Chemistry.     It  contains : — 

I.  A  series  of  simple  Tables  for  the  analysis  of  unknown  substances  of  all 
kinds.  2.  A  brief  description  of  all  the  practically  important  single  substances 
likely  to  be  met  with  in  ordinary  analysis.  3.  Simple  directions  and  illustra- 
tions relating  to  Chemical  Manipulation.  4.  A  system  of  Tables  for  the  detec- 
tion of  unknown  substances  with  the  aid  of  the  Blowpipe.  5.  Short  instructions 
upon  the  purchase  and  preparation  of  the  tests  intended  for  those  who  have  not 
access  to  a  Laboratory. 

"  A  great  amount  of  valuable  practical  information  is  here  condensed  into  a  book  of  260  pages,  such  as  only  a 
practical  teacher  could  prepare." — Ne2u  England  ycnirnal  of  Education. 

BRUEN.     PHYSICAL  DIAGNOSIS. 

A  Pocket  Book  of  Physical  Diagnosis,  for  Physicians  and  Students.  By 
Edward  T.  Bruen,  m.d.,  Asst.  Prof,  of  Clinical  Medicine,  University  of  Penn'a. 
Illustrated  by  Original  Wood  Engravings.    i2mo.   Extra  Cloth.  Price  %i.oo 

BENNETT.     NUTRITION  IN  HEALTH  AND  DISEASE. 

A  Contribution  to  Hygiene  and  Clinical  MediK;ine.  By  J.  Henry  Ben- 
nett, M.D.     Third  Edition,  Revised  and  Enlarged.     Cloth.  Price  $2.50 

BY   SAME   AUTHOR. 

THE    TREATMENT    OF     PULMONARY     CONSUMPTION 
BY  HYGIENE,  CLIMATE  AND  MEDICINE. 

With  an  Appendix  on  the  Sanitaria  of  the  United  States,  Switzerland  and 
the  Balearic  Islands.     Third  Edition  much  Enlarged.  Price  $2.50 

"Any  physician  may  take  it  up  with  every  feeling  of  confidence  that  the  views  enunciated  by  the  author  will  be 
found  to  be  able,  honest  and  orthodox." — Medico- Chirurgical  Review. 

BERKART,  ASTHMA. 

The  Pathology  and  Treatment  of  Asthma.  By  Joseph  B.  Berkart,  m.d.' 
8vo.  Price  $2.50 


PUB  Lie  A  TIONS. 


BEALE  ON  SLIGHT  AILMENTS.     New  Edition.     Just  Ready. 

Slight  Ailments,  Their  Nature  and  Treatment.  By  Lionel  S.  Beale,  m.d., 
F.R.S.,  Professor  of  Practice,  King's  Medical  College,  London.  Second  Edition. 
Enlarged  and  Illustrated.  Price,  Cloth,  $1.25  ;   Paper  covers,  .75  cents. 

Fine  Edition,  Heavy  Paper.  Extra  Cloth,  Price  ^1.75 

OUTLINE   OF   CONTENTS. 
Introductory.    The  Tongue  in  Health  and  Slight  Ailments.   Appetite.    Nausea.    Thirst.    Hunger.    Indigestion, 
its  Nature  and  Treatment.     Constipation,  its  Treatment.     Diarrhoea.     Vertigo.     Giddiness.     Biliousness.     Sick 
Headache.     Neuralgia.     Rheumatism.     The  Feverish  and  Inflammatory  State.     Of  the  Actual  Changes  in  Fever 
and  Inflammation.     Common  Forms  of  Slight  Inflammation,  etc.,  etc. 

"We  venture  to  say  that  among  the  numerous  medical  publications  issued  during  1880,  there  has  been  none 
which  will  prove  more  useful  to  the  young  general  practitioner,  for  whom  it  is  really  intended,  than  this  volume, 
while  the  time  of  the  older  physician  might  be  much  more  unprofitably  spent." — American  yournal  of  Medical 
Science. 

BY   SAME  AUTHOR. 

ON  LIFE  AND  VITAL  ACTION  IN  HEALTH  AND  DISEASE. 
i2mo.  Price  $2.00 

THE  USE  OF  THE  MICROSCOPE  IN  PRACTICAL  MEDI- 
CINE. 

For  Students  and  Practitioners,  with  full  directions  for  examining  the  various 
secretions,  etc.,  in  the  Microscope.  Fourth  Edition.  500  Illustrations.  Much 
enlarged.     8vo.  Price  $7.50 

"  We  have  before  us  Prof.  Beale's  work.  The  Micro-  |        "  As  a  microscopical    observer,  and  a  histological 
scope  in  Medicine,  a  book  which  it  gives  us  pleasure  to        manipulator,  his  (Dr.  Beale)  skill  and  eminence   are 
recommend  to  every  student  of  microscopy,  whether  he        generally  conceded." — Popular  Science  Monthly. 
be  a  physician  or  naturalist." — Jour^ial  of  the  Fratik- 

lin  Institute,  Philadelphia.  \ 

HOW  TO  WORK  WITH  THE  MICROSCOPE. 

A  Complete  Manual  of  Microscopical  Manipulation,  containing  a  full  descrip- 
tion of  many  new  processes  of  investigation,  with  directions  for  examining  ob- 
jects under  the  highest  powers,  and  for  taking  photographs  of  microscopic 
objects.  Fifth  Edition.  Containing  over  400  Illustrations,  many  of  them  colored. 
Octavo.  Price  $7.50 

"  The  Encyclopaedic  character  of  this  last  edition  of  Dr.  Beale's  well  known  work  on  the  Microscope  renders 
it  impossible  to  present  an  abstract  of  its  contents  ;  suffice  it  to  say,  that  anything  in  his  department  upon  which 
the  physican  can  desire  such  information  will  be  found  here,  and  much  more  in  addition.  It  is,  moreover,  a  store- 
house of  facts,  most  valuable  to  the  physician,  and  is  indispensable  to  every  one  who  uses  the  microscope." — 
Atnerican  Journal  of  Medical  Science. 

BIOPLASM. 

A  Contribution  to  the  Physiology  of  Life,  or  an  Introduction  to  the  Study  of 
Physiology  and  Medicine,  for  Students.     With  numerous  Illustrations. 

PROTOPLASM;  or  MATTER  AND  LIFE. 

Third  Edition,   very  miich  enlarged.     Nearly  350  pages.     Sixteen  Colored 

Plates.   Part  I.  Dissentient.  Part  11.   Demonstrative.    Part  iii.  Suggestive. 

One  volume.  Price  $3.00 

LIFE    THEORIES ;    Their  Influence   upon  Religious    Thought. 

Six  Colored  Plates.  Price  $2.00 

ONE  HUNDRED  URINARY  DEPOSITS, 

On  two  sheets,  for  the  Hospital,  Laboratory,  or  Surgery.  Each  Sheet  $1.00,  or 
on  Rollers,  Price  $1.25 

BERNAY,  CHEMISTRY. 

Notes  for  Students  in  Chemistry.  Compiled  from  Fowne's  and  other  manuals. 
By  Albert  J.  Bernay,  PH.D.     Sixth  Edition.     i2mo.  Price  $1.25 

BENTLEY'S  STUDENTS'  BOTANY. 

The  Students'  Guide  to  Structural  and  Physiological  Botany.  By  Professor 
Robert  Bentley.     Illustrated  by  nearly  500  Wood  Engravings. 

In  Preparatioti. 


p.  BLAKISTON,  SON  &-  CO.'S 


BEASLEY.     THE  BOOK  OF  PRESCRIPTIONS. 

Containing  over  3100  Prescriptions,  collected  from  the  Practice  of  the  most 
Eminent  Physicians  and  Surgeons — English,  French  and  American ;  a  Com- 
pendious History  of  the  Materia  Medica,  Lists  of  the  Doses  of  all  Officinal  and 
Established  Preparations,  and  an  Index  of  Diseases  and  their  Remedies.  By 
Henrv  Beasley.     Sixth  Edition,  Revised  and  Enlarged.  Price  $2.25 

BY    SAME   AUTHOR. 

THE  DRUGGIST'S  GENERAL  RECEIPT-BOOK. 

Comprising  a  copious  Veterinary  Formulary;  numerous  Recipes  in  Patent 
and  Proprietary  Medicines,  Druggists'  Nostrums,  etc.;  Perfumery  and  Cos- 
metics; Beverages,  Dietetic  Articles  and  Condiments;  Trade  Chemicals,  Scien- 
tific Processes,  and  an  Appendix  of  Useful  Tables.    Eighth  Edition.    Price  $2.25 

THE  POCKET  FORMULARY  and  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias. 

Comprising  Standard  and  Approved  Formulae  for  the  Preparations  and  Com- 
pounds   Employed   in    Medical    Practice.      Tenth    Edition.     511    pp.      i8mo. 

Price  $2.25 
BENTLEY  AND  TRIMEN'S  MEDICINAL  PLANTS. 

A  New  Illustrated  Work,  containing  full  botanical  descriptions,  with  an  account 
of  the  properties  and  usesof  the  principal  plants  employed  in  medicine,  especial 
attention  being  paid  to  those  which  are  officinal  in  the  British  and  United  States 
Pharmacopoeias.  The  plants  which  supply  food  and  substances  required  by  the 
sick  and  convalescent  are  also  included.  By  R.  Bentley,  f.r.s.,  Professor  of 
Botany,  King's  College,  London,  and  H.  Trimen,  m.b.,  f.h.s..  Department  of 
Botany,  British  Museum.  Each  species  illustrated  by  a  colored  plate  drawn 
from  nature.     In  Forty-two  parts.     Eight  colored  plates  in  each  part. 

Price  $2  each,  or  handsomely  bound  in  4  volumes.  Half  Morocco,  $90.00 

"  It  would  be  impossible   to   enumerate  all  the  new  i  "  This  work  may  be  recommended  as  a  most  useful 

planLs  that  are  here  delineated.     The  result  is  a  work  I  one   to   druggists,   and   all  who  desire   to  be  familiar 

which,  from  all  points  of  view,  is  a  credit  to  the  scientific  I  with   the   Botany  of  Medicinal  Plants." — Druggists' 

literature  of  the  day." — London  Lattcei.  Circular. 

"It  is  an  indispensable  work  of  reference  to  every  one  |  "The  work  when  complete  (it    is    now   complete) 

interested  in  pharmaceutical  Botanj-." — London  Phar-  \  will  be  the  most  valuable  corapend  of  Medical   Botany 

THoceutical  yournal.  \  ever  published." — Boston  your 7ial  nf  Chemistry. 

BRUBAKER,  PHYSIOLOGY. 

A  Compend  of  Physiology  specially  adapted  for  the  use  of  Students  and  Phy- 
sicians.    "  No.  4,  ?  Ouiz-Compend  Series  ?"     i2mo,  Cloth.  Price  $1.00 

"  Dr.  Brubaker  deserves  the  hearty  thanks  of  medical  students  for  his  Compend  of  Physiology.  He  has 
arranged  the  fundamental  and  practical  principles  of  the  science  in  a  particularly  inviting  and  accessible 
manner.  I  have  already  introduced  the  work  to  my  class." — Maurice  N.  Miller,  M.D.,  Demonstrator  of 
J-'/':\siology,  Medical  Depart7ne7it  University  oj" the  City  of  New   York. 

BYFORD.     DISEASES  OF  WOMEN.     New  Revised  Edition. 

The  Practice  of  Medicine  and  Surgery,  as  applied  to  the  Diseases  of  Women. 
By  W.  H.  Byford,  a.m.,  m.d..  Professor  of  Obstetrics  and  The  Diseases  of  Wo- 
men and  Children,  in  the  Chicago  Medical  College.  Third  Edition.  Revised 
and  Enlarged,  much  of  it  rewritten,    with  numerous  additional  illustrations. 

Price,  in  Cloth  $5.00;  Leather,  $6.00 

"  The  treatise  is  as  complete  a  one  as  the  present  "  The  author  is  an  experienced  writer,  an  able  teach- 

state  of  our  science  will  admit  of  being  written.     We  I    er  in  his  department,  and  has  embodied  in  the  present 

commend  it  to  the  diligent  study  of  everj'  practitioner  work  the  results  of  a  wide  field  of  practical  observa- 

and  student,  as  a  work  calculated  to  inculcate  sound  '    tion.    We  have  not  had  time  to  read  its  pages  critically, 

principles    and    lead    to    enlightened   practice. — jS'eiu  but  freely  commend  it  to  all  our  readers,  as  one  of  the 

York  Medical  Record.  '    most  valuable  practical  works  issued  from  the  Ameri- 
can press." — Chicago  Medical  Examiner. 

BY    same   author. 

ON  THE  UTERUS.     The  Chronic  Inflammation  and  Displace- 
ment of  the  Unimpregnated  Uterus. 

An  Enlarged  Edition,  with  Illustrations.     8vo.  Price  $2.50 

"A  good  book  from  a  good  man." — American  yournal  Medical  Science. 

"  It  is  a  sensible,  practical  work,  and  cannot  fail  to  be  read  with  interest  and  profit." — Boston  Medical  and 
Surgical  yournal. 


PUB  Lie  A  TIONS. 


BRAUNE,  TOPOGRAPHICAL  ANATOMY. 

An  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates,  Photo- 
graphed on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other  illus- 
trations. By  WiLHELM  Braune,  Professor  of  Anatomy  at  Leipzig.  Translated 
and  Edited  by  Edward  Bellamy,  f.r.c.s.,  Lecturer  on  Anatomy,  Charing 
Cross  Hospital,  London.     Quarto.     Price,  Cloth,    ^8.00  ;  Half  Morocco,  $10.00 

"As  a  whole  the  work  cannot  fail  to  meet  with  a  hearty  reception  by  every  progressive  student  of  the  human 
body.  To  the  surgeon  it  is  a  contribution  to  the  study  of  topographical  anatomy  which  needs  to  be  known  to  be 
properly  appreciated  To  such  practitioners  who  reside  in  large  cities,  where  anatomy  can  be  studied  upon  the 
cadaver,  it  will  afford  a  valuable  aid,  while  to  those  who  are  without  such  means  of  study  it  is  an  almost  indis- 
pensable addition  to  a  working  library." — New  York  Medical  Record. 

"  We  commend  the  book  most  heartily  to  the  Profession." — Ainerican  yournal  0/ Medical  Science . 

BUCKNILL  AND  TUKE  ON  INSANITY. 

A  Manual  of  Pyschological  Medicine :  containing  the  Lunacy  Laws,  the 
Nosology,  (Etiology,  Statistics,  Description,  Diagnosis,  Pathology  (including 
morbid  Histology),  and  Treatment  of  Insanity.  By  John  Charles  Bucknill, 
M.D.,  F.R.S.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p.  Fourth  Edition,  much 
enlarged,  with  twelve  lithographic  plates,  and  numerous  illustrations.     Octavo. 

Price  $8.00 

"  We  have  read  no  book  in  any  language,  and  certainly  none  in  English,  which   ought  to  be  preferred  to    this 
for  a  text  book,  by  those  who  wish  to  make  a  thorough  study  of  the  subject. — Edinburgh  Medical  yournal. 
"  We  can  heartily  commend  the  work. — American  yournal  of  Insanity. 

BURDETT,  HOSPITALS. 

Pay  Hospitals  and  Paying  Wards  throughout  the  World.  Facts  in  support 
of  a  rearrangement  of  the  system  of  Medical  Relief.  By  Henry  C.  Burdett. 
Svo.  Price  $2.25 

"  Mr.  Burdett  displays  and  discusses  the  whole  scheme  of  Hospital  accommodation  with  a  comprehensive 
understanding  of  its  nature  and  extent. — American  Practitioner. 

BY  SAME  author. 

COTTAGE  HOSPITALS. 

General,  Fever,  and  Convalescent :  their  Progress,  Management,  and  Work. 
Second  Edition,  rewritten  and  much  Enlarged,  with  many  Plans  and  Illustra- 
tions.    Crown  Svo.  Price  $4.50 

Contents. — Chap. — i.  Origin  and  Growth  of  the  Cottage  Hospital  System.  2.  Comparative  Success  of 
Treatment  in  large  and  small  Hospitals.  3.  Finance.  4.  Cottage  Hospital  Construction  and  Sanitary  Arrange- 
ments. 5.  The  Medical  and  Nursing  Departments.  6.  Domestic  Supervision  and  General  Management.  7. 
Cottage  Hospital  Appliances  and  Fittings.  8.  Cottage  Fever  Hospitals.  9.  Midwifery  in  Cottage  Hospitals .  10. 
Remunerative  Paying  Patients.  11.  Convalescent  Cottages .  12.  Cottage  Hospitals  in  America.  13.  Mortu- 
aries. 14.  A  more  Detailed  Account  of  certain  Cottage  Hospitals,  with  Plans  and  Elevations.  15.  Selected  and 
Model  Plans  criticised  and  compared,  with  a  detailed  description  of  various  Hospitals.  16.  Peculiarities  and 
Special  Features  in  the  Working  of  Cottage  Hospitals.  With  an  Appendix  containing  much  statistical  and  useful 
information. 

"  Mr.  Burdett's  book  contains  a  mass  of  information,  statistical,  financial,  architectural,  and  hygienic,  which  has 
already  proved  of  great  practical  utility  to  those  interested  in  cottage  hospitals,  and  we  can  confidently  recom- 
mend this  second  edition  to  all  who  are  in  search  of  the  kind  of  information  which  it  contains." — Lancet. 

BUZZARD,  NERVOUS  DISEASES. 

Clinical  Lectures  on  Diseases  of  the  Nervous  System.  By  Thos.  Buzzard, 
M.D.     Illustrated.     Octavo.  Price  $5.00 

CARPENTER,  THE  MICROSCOPE.     Sixth  Edition. 

The  Microscope  and  its  Revelations.  By  W.  B.  Carpenter,  m.d.,  f.r.s. 
Sixth  Edition.     Revised  and  Enlarged,  with  over  500  Illustrations.     Price  $5.50 

"  Not  only  the  student  of  medicine,  but  amateurs,  I        "As  a  text  book  of  Microscopy  in  its  special  relation 

and  others  interested  in  the  study  of  natural  history,  to  natural  history  and  general  science,  the  work  before 

will  find  this  volume  one  of  great  practical  value." —  us  stands  confessedly  first,  and  is  alone  sufficient   to 

N^■w  York  Medical  yournal.  supply  the  wants  of  the  ordinary  student." — American 

"It  is  by  far  the  most  complete  and  useful  treatjse  yournal  of  Microscopy. 

now  accessible  to  the  student." — The  Technologist.  I 


10  p.  BLAKISTON,  SON  &-  CO:S 


CARTER,  EYESIGHT.     New  Edition  now  ready. 

Eyesight,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation  of 
Vision.  By  Robert  Brudenell  Carter,  f.r.c.s.  Second  Edition,  witla  50 
Illustrations,  Test  Types,  etc.     i2mo.  Price,  Cloth,  $1.25 

"  It  is  written  in  a  lucid  and  agreeable  style,  conveying  an  easily  comprehensible  account  of  the  structure  of 
the  eye  and  the  function  of  vision,  and  gives  a  description  of  the  principal  anomalies  of  the  latter,  at  the  same 
time  inculcating  such  salutary  advice  as  may  be  beneficial  for  the  preservation  of  sight." — London  Medical 
Times  a^id  Gazette. 

"  There  is  much  wholesome  advice  given  on  the  '  Care  of  the  Eyes  in  Infancy  and  Childhood,'  and  ontliis 
account,  if  no  other,  the  book  should  be  in  the  hands  of  everj'  parent  and  teacher." — St.  Louis  Courier  of 
Medicine. 

CARTER,  PRACTICE  OF  MEDICINE. 

Elements  of  Practical  Medicine.  By  Alfred  H.  Carter,  m.d.,  London, 
Member  of  the  Royal  College  of  Physicians  ;  Physician  to  the  Queen's  Hos- 
pital, Birmingham,  etc.     Crown  8vo.  Price  I3.00 

"  The  object  of  this  volume  is  to  provide  the  student  with  a  general  introduction  to  the  study  of  Medicine, 
and  to  bring  the  essentials  of  the  subject,  so  far  as  required  for  the  ordinarj'  medical  qualifications,  within  the 
grasp  of  those  who  have  not  the  time  or  leisure  to  read  the  larger  and  more  elaborate  works  on  Practice." — 
Preface. 

"  Dr.  Carter  is  favorably  known  as  a  London  physician  of  learning  and  experience,  and  a  clear  writer.  He 
aims  to  give  a  judicial  epitome  of  practical  medicine,  and  this  is  a  well-prepared  book." — Philadelphia  Medi- 
cal and  Surgical  Reporter. 

CULLINGWORTH,  ON  NURSING.     Illustrated. 

A  Manual  of  Nursing,  Medical  and  Surgical.  By  Charles  J.  Culling- 
WORTH,  M.D.,  Physician  to  St.  Mary's  Hospital,  Manchester,  England.  With 
eighteen  Illustrations.     i2mo.  Cloth,  $1.00 

CAZEAUX'S  GREAT  OBSTETRICAL  TEXT-BOOK. 

A  Theoretical  and  Practical  Treatise,  including  the  Diseases  of  Pregnancy 
and  Parturition.  By  P.  Cazeaux,  Adjunct  Professor  in  the  Faculty  of  Medi- 
cine of  Paris,  etc.  etc.  Revised  and  Annotated  by  S.  Tarxier,  Former  Clini- 
cal Chief  of  the  Lying-in-Hospital,  etc.,  etc.  Sixth  American  from  the  Seventh 
French  Edition.  Translated  by  Wm.  R.  Bullock,  m.d.  One  volume.  Royal 
Octavo,  over  iioo  pages,  with  Lithographic  and  175  other  Illustrations  on 
Wood.  Price,  Cloth,  $6.00;  Leather,  $7.00 

M.  Cazeaux's  great  work  on  Obstetrics  has  become  classical  in  its  character,  and 
almost  an  Encyclopsedia  in  its  fulness.  Written  expressly  for  the  use  of  students  of 
medicine,  and  those  of  midwifery  especially,  its  teachings  are  plain  and  explicit, 
presenting  a  condensed  summary  of  the  leading  principles  established  by  the  masters 
of  the  obstetric  art,  and  such  clear,  practical  directions  for  the  management  of  the 
pregnant,  parturient,  and  puerperal  states,  as  have  been  sanctioned  by  the  most 
authoritative  practitioners,  and  confirmed  by  the  author's  own  experience.  Collect- 
ing his  materials  from  the  writings  of  the  entire  body  of  antecedent  writers,  carefully 
testing  their  correctness  and  value  by  his  own  daily  experience,  and  rejecting  all  such 
as  were  falsified  by  the  numerous  cases  brought  under  his  own  immediate  observa- 
tion, he  has  formed  out  of  them  a  body  of  doctrine,  and  a  system  of  practical  rules, 
which  he  illustrates  and  enforces  in  the  clearest  and  most  simple  manner  possible. 

"The  edition  before  us  is  one  of  unquestionable  ex-  "  It  is  unquestionably  a  work  of  the  highest  excel- 
cellence.  Everj'  portion  of  it  has  undergone  a  thorough  lence,  rich  in  information,  and  perhaps  fuller  in  details 
revision,  and  no  little  modification  ;  while  copious  than  any  text-book  with  which  we  are  acquainted, 
and  important  additions  have  been  made  to  nearly  '  The  author  has  not  merely  treated  of  every  question 
ever\-  part  of  it.     It  is  well  and  beautifully  illustrated  !  which  relates  to  the  business  of  parturition,  but  he  has 


by  numerous  wood  and  lithographic  engra%"ings,  and 
in  typographical  execution  wiil  bear  a  favorable  com- 
parison with  other  works  of  the  same  class.".(4>«friV:a« 
Medical  yournal. 

"  The  translation  of  Dr.  Bullock  is  remarkablj'  well 


done  so  with  judgment  and    ability." — British  and 
Foreign  Medico-  Chirurgical  Revieiu. 

"  No  work,  in  our  estimation,  bears  any  comparison 
to  Cazeaux,  in  its  entire  perfectness  ;  and  if  we  were 
called  upon   to  rely  alone  on  one  work  on  accouch- 


done.  We  can  recommend  this  work  to  those  espe-  i  ments,  our  choice  would  fall  upon  the  book  before  us 
ciallj-  interested  in  the  subject  treated,  and  can  espe-  |  without  any  kind  of  hesitation." — U'est.  your.ofMed- 
cially  recommend   the  American  edition." — liledical  ;  iciiie  and  Surgery. 

Times  and  Gazette.  i       <<  -We  know  of  no  work  on  this  all-important  branch 

"  We  do  not  hesitate  to  say  that  it  is  now  the  most  of  our  profession  that  we  can  commend  to  the  student 
complete  and  best  treatise  on  the  subject  in  the  Eng-  or  practitioner  as  a  safe  guide  before  this." — Chicago 
lish  language." — Buffalo  Medical  journal.  |  Medical  jfouryzal. 


PUBLICA  TIONS. 


CHARTERIS,  PRACTICE  OF  MEDICINE. 

Hand-Book  of  the  Practice  of  Medicine.  By  M.  Charteris,  m.d.,  Member 
of  Hospital  Staff  and  Professor  in  University  of  Glasgow.  With  Microscopic  and 
other  illustrations.  Price  $1.25 

"  We  have  not  often  met  with  a  book  which  can  be  so  confidently  recommended  to  physicians  or  tnen  in  general 
practice . ' ' — Lancet. 

"  The  style  in  which  it  is  written  is  clear  and  attractive.  The  illustrations  are  a  marked  feature  in  it.  It  can 
be  recommended  as  a  very  reliable,  handy  book,  well  adapted  for  ready  reference." — New  Remedies. 

CHAVASSE  ON  CHILDREN. 

The  Mental  Culture  and  Training  of  Children.     By  Pye  Henry  Chavasse. 

i2mo.  Price,  Paper  covers,  .50;  Cloth,  $1.00 

The  mental  culture  and  training  of  children  is  of  immense  importance.     Many 

children  are  so  wretchedly  trained,  or  rather  not  trained  at  all,  and  so  mismanaged, 

that  a  few  thoughts  on  this  subject  cannot  be  thrown  away,  even  upon  the  most 

careful. 

CLAY  ON  OBSTETRIC  SURGERY.     Third  Edition. 

A  complete  Hand-Book  of  Obstetric  Surgery,  with  Rules  for  every  Emergency 
and  Descriptiens  of  the  more  difficult  as  well  as  the  every  day  operations.  By 
Charles  Clay,  m.d.,  with  numerous  Illustrations.  From  the  Third  London 
Edition.     i2mo.  Paper  Covers,  .75  ;  Cloth,  $1.25 

"  It  is  a  useful  and  convenient  book  of  reference ;  the  illustrations  are  good,  and  the  book  will  be  found  of  value 
to  the  student  and  young  practitioner,  as  well  as  to  the  skilled  Obstetrician." — American  journal  of  Obstetrics. 

CLEVELAND,  POCKET  DICTIONARY. 

A  Pronouncing  Medical  Lexicon,  containing  correct  Pronunciation  and  Defi- 
nition of  terms  used  in  medicine  and  the  collateral  sciences.  By  C.  H.  Cleve- 
land, m.d.     Twenty-ninth  Edition.     i6mo. 

Price,  Cloth,  75  cents  ;  Tucks  with  Pocket,  $1.00 
This  is  a  most  convenient  size  for  the  pocket,  and  contains  all  the  principal  words 
in  use,  together  with  rules  for  pronunciation,  abbreviations  used  in  prescriptions,  list 
of  poisons,  their  antidotes,  etc. 

COHEN,  INHALATION.     Enlarged  Edition. 

Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of  the  Ap- 
paratus Employed,  etc.  By  J.  SOLis  Cohen,  m.d.  With  cases  and  Illustrations. 
A  New  Enlarged  Edition.     8vo.  Price  ^2.50 

"  The  book  has  the  merit  of  containing  much  information  that  cannot  be  found  elsewhere." — N.  Y.  Medical 
yournal. 
"  One  of  the  best  treatises  we  have  seen  on  this  subject."— Jlledicat  Times  and  Gazette. 

BY   SAME  AUTHOR. 

CROUP, 

In  its  Relation  to  Tracheotomy.     8vo.  Price  |i.oo 

CLARKE,  SURGERY. 

Outlines  of  Surgery  and  Surgical  Pathology,  including  the  Diagnosis  and 
Treatment  of  Obscure  and  Urgent  Cases.  By  F.  LeGross  Clarke,  f.r.s. 
Second  Edition.     8vo.  Price  |2.oo 

COBBOLD,  PARASITES. 

A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some  account  of 
the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  illustrations. 
8vo.  Price  $5.00 


p.  BLAKISTON,  SON  &>  CO:s 


COLES,  THE  MOUTH.     Third  Edition,  just  ready. 

Deformities  of  the  Mouth,  Congenital  and  Acquired,  with  Their  Mechanical 
Treatment.  By  Oakley  Coles,  d.d.s.  Third  Edition.  83  Wood  Engravings 
and  96  Drawings  on  Stone.     8vo.  Price  $4.50 

"Altogether  we  must  heartily  congratulate  Mr.  Coles  on  this  creditable  completion  of  a  work  which  cannot 
|ut  redound  to  his  credit  wherever  it  is  known." — British  yournal  of  Dental  Science. 
"  We  recommend  this  book  to  the  study  of  both  surgeons  and  dentists." — London  Lancet. 

BY   SAME  AUTHOR. 

A  MANUAL  OF  DENTAL  MECHANICS. 

Containing  much  information  of  a  practical  nature,  upon  the  Materials  and 
Appliances  used  in  Mechanical  Dentistry.  For  Practitioners  and  Students. 
Second  Edition,  with  140  Illustrations.     i2mo. 

THE  DENTAL  STUDENT'S  NOTE-BOOK. 

A  new  Edition.     i6mo.  Price  |i.oo 

CORMACK,  CLINICAL  STUDIES. 

Illustrated  by  Cases  Observed  in  Hospital  and  Private  Practice.  By  Sir 
John  Rose  CoRMACK,  M..D.,  K.B.,  etc.   Illustrated.   2  vols.   1,127  pp.  Price  55.00 

COURTY,  THE  UTERUS,  OVARIES,  ETC. 

A  Practical  Treatise  on  Diseases  of  the  Uterus,  Ovaries,  and  Fallopian 
Tubes.  By  Prof.  A.  Courty,  of  Montpelher,  France.  Translated  from  the 
Third  Edition  by  his  pupil  and  assistant,  Agnes  McLaren,  m.d.,  m.k.q.c.p.i. 
With  a  Preface  by  J.  Matthews  Duncan,  m.d.,  ll.d.,  f.r.s.,  Obstetric  Physi- 
cian to  Saint  Bartholomew's  Hosnital,  London.  With  431  Illustrations.  One 
Vol.,  8vo.    Price,  in  Handsome  Cloth,  $6.00 ;  Full  Sheep,  Raised  Bands,  $7.00 

OUTLINE  OF   CONTENTS. 

TPODUCTION. — On   the    Anatomy,    Physiology,  and  Teratology  of  the  Organs  of  Generation.     Part  i. — 

General  Survey  of  Uterine  Diseases.      Diagnosis  of  Uterine   Diseases  in  General;   Treatment  of 

Uterine  Diseases  in  General;  General  Characteristics  of  Uterine  Diseases.     Part  ii. — Uterine  Diseases 

IN  Detail.     Functional  Disorders  ;  Changes  of  Position ;    Morbid   States  without  Neoplasm ;    Organic 

Alterations;  Diseases  of  the  Uterine  Appendages;   Pelvic  Hemorrhages  and  Peri-uterine  Haematocele; 

Cyst  of  the  Ovary  and  Genito-pelvic  Tumor;  Sterility,  etc.,  etc.     Index. 

"  Courty's  work  has,  since  its  first  publication,  been  recognized  everywhere.     In  France,  its  position  is 

attested  by  the  sale  of  two  editions,  numbering,  I  am  told,  ten  thousand  copies,  and  by  the  appearance  of 

another,  the  third  edition.     I  recommend  to  the  careful  study  of  my  professional  brethren  a  book  which  has 

already  been  crowned  by  the  Institute  of  France." — J.  Matthews  Duncan. 

CURLING,  ON  THE  TESTIS. 

A  Practical  Treatise  on  the  Diseases  of  the  Testis,  Spermatic  Cord,  and 
Scrotum.  By  T.  B.  Curling,  m.d.,  f.r.s.  Fourth  Edition,  Enlarged  and  Il- 
lustrated.    8vo.  Price  $5.50 

"  We  believe  this  work  to  be  the  most  trustworthy  that  can  be  consulted  in  this  Department  of  Surgery, 

his  pages   abound  with  valuable  suggestions  and  cautions   that  mark  his  intimate  knowledge  of  the 

subject."- — Lcmdon  Practitioner. 

COOPER'S  SURGICAL  DICTIONARY. 

A  Dictionary  of  Practical  Surgery  and  Encyclopaedia  of  Surgical  Science. 
By  Samuel  Cooper.  New  Edition,  brought  down  to  the  present  time.  By 
Samuel  A.  Lane,  f.r.c.S.,  assisted  by  various  eminent  Surgeons.  In  two 
vols.  Price  $12.00 

COTTLE,   ON  THE  HAIR. 

The  Hair  in  Health  and  Disease.  By  E.  W.  Cottle,  m.d.  Partly  from  the 
notes  of  the  late  George  Nayler.     i8mo. 

CORFIELD,    DWELLING  HOUSES. 

The  Sanitary  Construction  and  Arrangement  of  Dwelling  Houses.  By  W. 
H.  CoRFiELD,  m.a.,  m.d.  Enlarged  Edition,  with  Plans  and  Illustrations. 
I2mo.  Price  $1.25 


PUB  Lie  A  TIONS. 


n 


COULSON,  THE  BLADDER.     Sixth  Edition. 

Diseases  of  the  Bladder  and  Prostate  Gland.  By  Walter  J.  Coulson,  f.r.c.s. 
Sixth  Edition.     Revised  and  Enlarged,  with  22  Engravings.     8vo.      Price  $6.40 

CRIPPS,  THE  RECTUM. 

Cancer  of  the  Rectum.  Its  Pathology,  Diagnosis  and  Treatment.  By.  W. 
Harrison  Cripps,  f.r.c.s.     Illustrated  by  Plates.     8vo.  Price  $2.40 

DAY  ON  CHILDREN.     Second  Edition.     Just  Ready. 

The  Diseases  of  Children.  A  Practical  and  Systematic  Treatise  for  Practi- 
tioners and  Students.  By  Wm.  H.  Day,  m.d.  Second  Edition.  Rev/ritten  and 
very  much  Enlarged.     8vo.     752  pp. 

"  Believing  the  work  well  adapted  to  meet  the  wants 
of  the  Student  as  well  as  the  Practitioner,  I  will  recom- 
mend it  to  the  classes  of  Rush  Medical  College." — ■ 
DeLeskie  Miller,  m.d.,  Chicago. 

"  On  the  whole,  we  must  confess  we  are  pleased  with 
this  book  and  can  heartily  recommend  it — a  recommen- 
dation which  it  does  not  appear  to  need,  as  it  has 
already  reached  its  second  edition." — Atnerican  jour- 
nal of  Medical  Science. 

DAY  ON   HEADACHES.     Fourth  Edition. 

The  Nature,  Causes,  and  Treatment  of  Headaches.  Fourth  Edition.  Illus- 
trated.    By  Wm.  Henry  Day,  m.d.     Octavo. 

Paper  Covers,  75  cents;     Cloth,  $1.25 

Summary  of  Contents. — Headache  from  Cerebral  Anaemia,  Cerebral  Hypersemia,  Sympathetic,  Congestive, 
Dyspeptic  or  Bilious  Headaches,  Headache  from  Plethora,  from  Exhaustion,  from  Change  in  Cerebral  Tissue, 
from  Affections  of  the  Periosteum,  Nervous  and  Nervo-Hyperaemic  Headache,  Toxaemic,  Rheumatic,  Arthritic 
or  Gouty  Headache,  Neuralgic  Headache,  and  Headaches  of  Childhood,  Early  and  Advanced  Life. 

"Well  worth  reading.     The  remarks  on  treatment  are  very  sensible."— .ffoj/ow  Medical  and  Surg,  yournal. 

DALBY,  ON  THE  EAR. 

The  Diseases  and  Injuries  of  the  Ear.  By  W.  B.  Dalby,  m.d..  Surgeon  and 
Lecturer  on  Aural  Surgery,  St.  George's  Hospital.     With  Illustrations.     i2mo. 

Price  $1.50 


Price,  Cloth,  $5.00;  Sheep,  $6.00 

"  Dr.  Day  brings  to  his  task  a  large  experience,  and 
evidences  a  very  thorough  knowledge  of  the  literature, 
native  and  foreign,  pertaining  to  this  special  branch  of 
medicine.  The  book  has  been  written  with  great  care, 
and  the  author  is  a  good  writer.  The  publisher's  part 
of  the  task  has  also  been  excellently  performed." — 
Boston  Medical  and  Surgical  Journal. 


'A  safe  and  readable  introduction  to  aural  surgery." 
Medical  Press  and  Circular. 

"  Dr.  Dalby  has  presented  us  with  a  very  readable 
little  book,  which  is  destined  to  render  ranch  service  in 
the  saving  of  ears." — N.  Y.  Medical  Journal. 


"The  lectures  occupy  2e6  pages,  are  clearly  and 
consisely  written,  contain  a  number  of  good  illustrations, 
and  are  well  worth  the  careful  study  of  both  student 
and  practitioner.  To  aurists  the  work  will  be  most 
welcome  and  valuable." — Sj>ecialist. 


DILLINGBERGER,     WOMEN     AND     CHILDREN'S     DIS- 
EASES. 

A  Hand-Book  of  the  Treatment  of  the  Diseases  Peculiar  to  Women  and  Chil- 
dren.    By  Dr.  Emil  Dillingberger.     i2mo.  Price  $1.50 

"  It  is  a  magnum  in  parvo.  The  style  is  simple,  clear,  lucid,  and  free  from  theoretical  discussion.  No  one  will 
regret  the  small  outlay  for  this  volume. — Richmond  and  Louisville  Medical  Journal. 

DUNGLISON,  THE  PHYSICIAN'S  REFERENCE  BOOK. 

The  Practitioner's  Ready  Reference  Book ;  a  Guide  in  OfRce  and  Bedside  Prac- 
tice ;  containing  Therapeutical  and  Practical  Hints,  Dietetic  Rules,  and  General 
Information.     By  Richard  J.  Dunglison,  m.d.     Fourth  Edition.     8vo. 

Price  $3.50 

"  We  can  heartily  commend  this  book  as  one  that  I  "  The  demand  for  a  second  edition  so  soon  after  the 
must  prove  very  useful  to  the  general  practitioner."—  publication  of  the  first  volume  shows  that  this  work  is 
The  Medical  Record.  \    appreciated  by  the  profession." — Caiiada  Lancet. 

DURKEE,  VENEREAL  DISEASES.     Sixth  Edition. 

Gonorrhoea  and  Syphilis.  By  Silas  Durkee,  m.d.  Sixth  Edition.  Revised 
and  Enlarged,  with  Portrait  and  Eight  Colored  Illustrations.     8vo.     Price  $3.50 

"  We  may,  finally,  recommend  Dr.  Durkee's  book  as  eminently  practical,  well  written,  full  of  excellent  counsel, 
and  worthy  of  being  cors  ilted  by  every  member  of  the  profession.  A  late  number  of  the  London  Medical  Times 
and  Gazette  also  speaks  of  the  book  in  terms  of  the  highest  approval." — Bjston  Medical  and  Surgical  Journal 


14  P.  BLAKISTON,  SON  &-  CO.'S 

DAGUENET,  OPHTHALMOSCOPY. 

A  Manual  of  Ophthalmoscopy,  for  the  Use  of  Students.  By  Dr.  Daguenet. 
Translated  from  the  French,  by  Dr.  C.  S.  Jeaffreson,  f.r.c.s.e.  Illustrated. 
i2mo.  Price  $1.50 

"Its  portable  size,  the  condensed  nature  of  its  text,  and  the  admirably  systematic  arrangement  of  its  contents, 
render  it  extremely  useful  as  a  pocket  manual  for  Students. —  Translator' s Preface. 

DOBELL,  "WINTER  COUGH  AND  CATARRH. 

On  Winter  Cough,  Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By 
Horace  Dobell,  m.d..  Lecturer  at  the  Royal  Hospital  for  Diseases  of  the 
Chest.     Third  Edition.     With  Colored  Plates.     8vo.  Price  $3.50 

BY    SAME   AUTHOR. 

ON  LOSS  OF  WEIGHT.     Revised  Edition. 

Blood  Spitting  and  Lung  Disease.  Colored  Frontispiece  of  Lung.  Tabular 
Map,  etc.     Second  Edition  Enlarged.     8vo.  Price  I4.00 

DOMVILLE,  ON  NURSING. 

A  Manual  for  Hospital  Nurses  and  others  engaged  in  attending  to  the  sick, 
4th  Edition.     With  Recipes  for  Sick  Room  Cookery,  etc.  Price  .75 

DRUITT'S  MODERN  SURGERY.     Eleventh  Edition. 

The  Surgeon's  Vade  Mecum;  a  Manual  of  Modern  Surgery.  By  Robert 
Druitt,  f.r.c.s.  Eleventh  Enlarged  Edition,  with  369  Illustrations.  864  pp. 
1878.  Price  $5.00 

This  is  a  most  complete,  accurate,  and  trustworthy  Hand,  or  Text-Book  of  Sur- 
gery. Unrivaled  as  a  book  for  the  Student.  Fully  illustrated,  and  brought  up  to 
the  present  state  of  the  science.     In  use  in  many  Medical  Colleges. 

DULLES,  ACCIDENTS. 

What  to  Do  First,  In  Accidents  and    Poisoning.     By  C.  W.  Dulles,  m.d. 
Second  Edition,  Enlarged,  with  new  Illustrations.  Cloth,  .75. 


"  Its  usefulness  entitles  it  to  a  wide  and  permanent 
circulation." — Boston  Gazette. 

"  A  complete  guide  for  sudden  emergencies. — Phila- 
delphia Ledger. 


"  So  plain  and  sensible  that  it  ought  to  be  introduced 
into    every    female     seminary. — Evening    Chronicle, 

Pittsburgh. 


EDWARDS,  BRIGHT'S  DISEASE.     New  Edition. 

How  a  Person  Affected  with  Bright's  Disease  Ought  to  Live.  By  Jos.  F.  Ed- 
wards, M.D.     Second  Edition.     i2mo.  Price  .75 

"  Physicians,  as  well  as  laymen,  will  find  the  work  interesting,  and  will  obtain  many  valuable  hints  as  to  the 
proper  hygiene  to  be  observed  in  this  disease." — Cincinnati  Medical  Ne-ws. 

BY   SAME   AUTHOR. 

CONSTIPATION.     New  Edition. 

Plainly  Treated  and  Relieved  Without  the  Use  of  Drugs.  Second  Edition. 
i2mo.  Price  .75 

MALARIA. 

Malaria  :  What  It  Means ;  How  to  Escape  It ;  Its  Symptoms ;  When  and 
Where  to  Look  for  It.     i2mo.  Price  .75 

VACCINATION  AND  SMALL-POX. 

Showing  the  Reasons  in  favor  of  Vaccination,  and  the  Fallacy  of  the  Argu- 
ments Advanced  against  it,  with  Hints  on  the  Management  and  Care  of  SmaH- 
Pox  patients.     i6mo.  Price  .50 

These  are  invaluable  little  treatises  upon  subjects  that  enter  painfully  into  the 
life  experiences  of  a  large  majority  of  the  human  family.  Dr.  Edwards  shows  not 
only  how  they  ftiay  be  avoided,  but  in  plain  and  simple  language  he  tells  those 
already  afflicted  with  them  how  they  may  find  relief. 


PUBLIC  A  TIONS. 


IS 


ELLIS,  DISEASES  OF  CHILDREN. 

A  Practical  Manual  of  the  Diseases  of  Children,  with  a  Formulary.  By  Ed- 
ward Ellis,  m.d.  Late  Physician  to  the  Victoria  Hospital  for  Children, 
London.     Fourth  Edition  Enlarged.     Now  Ready.  Price  $3.00 


BY   SAME  AUTHOR. 

WHAT  EVERY  MOTHER  SHOULD  KNOW. 

i2mo.  Price  .75 

"  It  is  only  too  true  that  our  children  have  to  dodge  through  the  early  part  of  life  as  through  a  labyrinth.  We 
must  be  thankful  to  meet  with  such  a  sensible  guide  for  them  as  Dr.  Ellis." — Pall  Mall  Gazette. 

FLUCKIGER,  THE  CINCHONA  BARKS. 

The  Cinchona  Barks  Pharmacognostically  Considered.  By  Professor  Fried- 
RiCH  Fluckiger,  of  Strasburg.  Translated  by  Frederick  B.  Power,  ph.d., 
formerly  Professor  of  Chemistry,  Philadelphia  College  of  Pharmacy,  now  Pro- 
fessor of  Materia  Medica  and  Pharmacy,  University  of  Wisconsin.  With  8 
Lithographic  Plates.     Royal  Octavo.  hi  Press. 

FENNER,  ON  VISION,   Second  Edition,   Enlarged. 

Vision ;  Its  Optical  Defects,  the  Adaptation  of  Spectacles,  Defects  of  Accommo- 
dation, etc.  By  C.  S.  Fenner,  m.d.  With  Test  Types  and  74  Illustrations. 
Second  Edition,  Revised  and  Enlarged.     8vo.  '  Price  $3.50 

FENWICK,  THE  PRACTICE  OF  MEDICINE. 

Outlines  of  the  Practice  of  Medicine.  With  Appropriate  Formulae  and  Illus- 
trations.    By  Samuel  Fenwick,  M.D. ,  Physician  to  the  London  Hospital.    i2mo. 

Price  $1.25 

"  This  little  work  displays  a  sound  judgment  in  the  arrangement  of  its  subject  matter,  and  an  intimate  acquaint- 
ance with  the  practice  of  medicine  possessed  by  but  few  writers,  and  should  have  been  elaborated  into  a  more 
comprehensive  work.     Of  all  the  hand-books  we  have  seen,  this  is  certainly  one  of  the  best." — Medical  Herald. 

"  It  is  an  eminently  practical  little  treatise,  pervaded  with  much  common  sense,  and  will  doubtless  be  found 
useful,  particularly  by  advanced  students." — Boston  Medical  and  Surgical  Journal. 


BY   SAME   AUTHOR. 

ON  THE  STOMACH. 

Atrophy  of  the  Stomach  and  Its  Effect  on  the  Nervous  Affections  of  the  Digest- 
ive Organs.     8vo.  Price  $3.20 

FOTHERGILL,  ON  THE  HEART.     Second  Edition. 

The  Heart  and  Its  Diseases.  With  Their  Treatment.  Including  the  Gouty 
Heart.  By  J.  Milner  Fothergill,  m.d.,  Associate  Fellow  of  the  College  of 
Physicians  of  Philadelphia,      Second  Edition,    Entirely   Re-written.      Octavo. 

Price  $3.50 


"  It  is  the  best,  as  well  as  the  most  recent  work  on 
the  subject  in  the  English  language." — Medical  Press 
and  Circular. 

"  The  most  interesting  chapter  is  undoubtedly  that 
on  the  gouty  heart,  a  subject  which  Dr.  Fothergill  has 
specially  studied,  and  on  which  he  entertains  views 
such  as  are  likely,  we  think,  to  be  generally  accepted 
by  clinical  physicians,  although  they  have  not  before 
been  stated,  so  far  as  we  are  aware,  with  the  ■  same 
breadth  of  view  and  extended  illustration." — British 
Medical  Journal. 


"  To  many  an  earnest  student  it  will  prove  a  Kght  in 
darkness ;  to  many  a  practitioner  cast  down  with  a 
sense  of  his  powerlessness  to  cope  with  the  rout  and 
demoralization  of  Nature's  forces,  a  present  help  in 
time  of  trouble." — Philadelphia  Medical  Times. 

"  The  work  throughout  is  a  masterpiece  of  graphic, 
lucid  writing,  full  of  good,  sound  teaching,  which  will 
be  appreciated  alike  by  the  practitioner  and  the  stu- 
dent."— Students'  Journal. 


FULTON,  ON  PHYSIOLOGY. 

A    Text-Book   of   Physiology.     By   J.   Fulton,   m.d..  Professor  at    Trinity 
Medical   College,    Toronto.      Second   Edition,  Illustrated   and   Revised.     8vo. 

Price  fi4-oo 


i6  P.  BLAKISTON,  SON  6-   CO:S 


FLO^VER,  DIAGRAMS  OF  THE  NERVES. 

Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their  Origin, 
Divisions,  and  Connections,  with  their  Distribution  to  the  various  Regions  of  the 
Cutaneous  Surface,  and  to  all  the  Muscles.  By  William  H.  Flower,  f.r.c.s., 
F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator  of  the 
Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly  revised. 
With  six  Large  Folio  Maps,  or  Diagrams.     Royal  Quarto.  Price  $3.50 

"Admirably  arranged,  and   will  be   of  incalculable  aid  to  the  student  of  anatomy.     Eacb  of  the  large  and  , 
beautiful  plates  is  accompanied  with  explanatory'  text." — N.  Y.  Medical  Record. 

"  The  nerves  and  ganglia  are  clearly  represented.     The  impressions  are  well  made,  and  no  doubt  the  diagrams 
will  prove  useful." — Medical  and  Surgical  Reporter. 

FLAGG,  PLASTIC  FILLING. 

Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities  of  De- 
cay in.  Teeth  below  Medium  in  Structure,  and  to  Difficult  and  Inaccessible 
Cavities  in  Teeth  of  all  Grades  of  Structure.  With  some  beautifully  executed 
Illustrations.  By  J.  Foster  Flagg,  d.d.s..  Professor  of  Dental  Pathology  and 
Therapeutics  in  Philadelphia  Dental  College.     Octavo.  Price  $3.00 

FOX,  W^ATER,  AIR  AND  FOOD. 

Sanitary  Examinations  of  Water,  Air  and  Food.  By  Cornelius  B.  Fox, 
M.D.     94  Engravings.     8vo.  Price  $4.00 

FOSTER,  CLINICAL  MEDICINE. 

Lectures  and  Essays  on  Clinical  Medicine.  By  Balthazar  Foster,  m.d. 
Illustrated.     8vo.  Price  $3.00 

"No  one  can  peruse_  the  thoughtfiil  comments  of  our  j  "  Tt  is  the  record  of  honest  work,  such  as  Dr.  Foster 

author  upon  everj' subject  he  considers,  without  feeling  I  may  be  proud  of ;  we  can  recommend  it  to  the  profession; 

himself  a  wiser  man  for  his  pains." — N.   Y.  Medical  \  it  maj' be  read  with  profit  and  advantage  by  both  prac- 

yournal.  \  titioner  and  student. — Edinburgh  Medical  yournal. 

FOX,  ATLAS  OF  SKIN  DISEASES. 

Complete  in  Eighteen  Parts,  each  containing  Four  Chromo-Lithographic  Plates, 
I'jiyith  Descriptive  Text  and  Notes  upon  Treatment.  In  all  72  large  colored  Plates. 
By  Tilbury  Fox,  m.d.,  f.r.c.p.,  Physician  to  the  Department  for  Skin  Diseases 
in  University  College  Hospital.     Folio  Size. 

Price  $1.00  each,  or  complete,  bound  in  cloth,  $20.00 

No  Atlas  of  Skin  Diseases  has  been  issued  in  this  country  for  many  years,  and  no 
complete  work  of  the  kind  is  now  procurable  by  the  Profession.  This  one,  brought 
out  under  the  editorial  supervision  and  care  of  Dr.  Tilbury  Fox  (the  most  distin- 
guished-WTiter  on  Cutaneous  Medicine  now  in  the  English  language),  is  partly  based 
upon  the  classical  work  of  Willan  and  Bateman  (now  entirely  out  of  print),  but  com- 
pletely remodeled,  so  as  to  represent  fully  the  Dermatology  of  the  present  day. 

'■'  Preference  wiU  be  given  to  this  work  over  Hebra ;  not  simply,  however,  because  it  is  a  home  production,  but 
by  reason  of  the  manner  of  its  execution,  the  excellent  delineation  of  disease,  and  the  natural  coloring  of  the  plates. 
.     .     The  letter-press  is  entirely  new.     In  the  accuracy  of  the  latter  the  subscriber  may  have  the  fullest  confi- 
dence, since  it  is  from  the  pen  of  Dr.  Tilbury  Fox." — British  and  Foreign  Medico-Chirurgical  Reznew. 

FRANKLAND,  WATER  ANALYSIS. 

Water  Analysis,  For  Sanitary  Purposes,  with  Hints  for  the  Interpretation  of 
Results.     By  E.  Frankland,  M.D.,  F.R.s.     Illustrated.     i2mo.  Price  |i. 00 

"The  author's  world-wide  reputation  will  commend  |  "The  work  is   one  which  physicians  practicing  ia 

this  manual  to  all  sanitarians,  and  they  will  not  be  dis-  I  the  country  and   in   villages   and  towns  remote  from 

appointed  in  finding  all  the  essentials  of  the  important  !  medical  centres  cannot  afford  to  be  without." — Medical 

subject  of  which  it  treats." — The  Sanitarian.  \  and  Surgical  Reporter. 

BY  SAME   AUTHOR. 

CHEMISTRY. 

How  to  Teach  Chemistry;  being  Six  Lectures  to  Science  Teachers.  Edited 
by  G.  George  Chaloner,  f.c.s.     Illustrated.     i2mo.  Price  $1.25 


PUB  Lie  A  TIONS.  17 


GILLIAM'S  PATHOLOGY.     Illustrated. 

The  Essentials  of  Pathology ;  a  Handbook  for  Students.  By  D.  Tod  Gilliam, 
M.D.,  Professor  of  Physiology,  formerly  Professor  of  Pathology,  Starhng  Medical 
College,  Columbus,  O.     With  47  Illustrations.     i2mo.  Cloth,  $2.00 

GALLABIN,  DISEASES  OF  WOMEN. 

The  Student's  Guide  to  the  Diseases  of  Women.  By  A.  Lewis  Gallabin,  m.a., 
M.D.,  F.R.c.P.     Illustrated  with  63  Engravings.      i2mo.  Price  $1.25 

BY   SAME   AUTHOR. 

A  MANUAL  OF  MIDWIFERY. 

For  Students  and  Practitioners.     Illustrated.  In  Press. 

"**Prof.  Gallabin  is  Obstetric  Physician  to  Guy's  Hospital,  London,  and  occupies 
the  chair  of  Midwifery  in  that  Institution.  His  work  in  this  department  has  been 
noted  for  its  perfection  and  practical  character. 

GROSS,  BIOGRAPHY  OF  JOHN  HUNTER. 

John  Hunter  and  His  Pupils.  By  S.  D.  Gross,  m.d..  Professor  of  Surgery  in 
Jefferson  Medical  College,  Philadelphia.  With  a  beautifully  executed  full  length 
Portrait  of  the  Author  in  his  Study.  A  Handsome  Octavo  volume.  Bound  in 
Beveled  Cloth.  Price  $1.50 

"  It  is  refreshing  to  read  the  story  of  a  life  so  fully  devoted  to  science,  and  the  reader  will  readily  appreciate 
Professor  Gross's  enthusiasm  for  his  subject,  which  led  him  to  extend  what  was  originally  intended  for  an  essay  to 
its  present  size. 

"  The  phototype  of  Sharp's  well-known  engraving  of  Sir  Joshua  Reynold's  portrait  is  an  excellent  reproduction, 
and  forms  a  fitting  and  handsome  frontispiece. 

"  The  volume  will  prove  an  ornament  to  the  study  table,  where  it  will  be  a  constant  incentive  to  whatever  'vi 
best  and  noblest  in  a  noble  profession." — Bjsto?i  Med.  and  Surgical  yournal. 

BY  SAME   AUTHOR. 

AMERICAN  MEDICAL  MEN. 

American  Medical  Biography  of  the  Nineteenth  Century,  with  portrait  of  Di. 
Benjamin  Rush.     Large  8vo. 

GLISAN,  TEXT-BOOK  OF  MODERN  MIDWIFERY. 

A  Text-Book  of  Modern  Midwifery.  By  Rodney  Glisan,  m.d..  Emeritus 
Professor  of  Midwifery  and  Diseases  of  Women  and  Children  in  the  Medical 
Department  of  Willamette  University,  Portland,  Oregon,  and  Late  President 
of  the  Oregon  State  Medical  Society.  With  129  Illustrations.  One  Volume, 
octavo,  624  pp.  Price,  in  Cloth  ^.oo;  in  Leather  |5-CX3 

GILL,  ON  INDIGESTION.     Third  Edition. 

Indigestion  ;  What  It  Is ;  What  It  Leads  To  ;  and  a  New  Method  of  Treating 
It.     By  John  Beadnell  Gill,  m.d.      Third  Edition.     i2mo,  |i-25 

GANT,  ON  THE  BLADDER  AND  PROSTATE. 

Diseases  of  the  Bladder  and  Prostate  Gland  and  Urethra,  including  a  Practical 
View  of  Urinary  Diseases,  Deposits  and  Calculi.  Fourth  Edition,  Revised  and 
Enlarged,  with  New  Illustrations.     i2mo.  Price  $3.00 

GIBBES,  STUDENT'S  PATHOLOGY. 

Practical  Histology  and  Pathology.  By  Heneage  Gibbes,  m.b.  i2mo. 
Cloth.  Price  ^2.00 

Chap.  i.  Introduction.  2.  On  Preparing  Tissues  for  Examination.  3.  On  Cutting  Sections.  4.  On  Staining, 
5.  On  Double  Staining.  6.  On  Mounting.  7.  Method  of  Obtaining  Animal  Tissues,  etc.  Practical  Histology, 
Pathology,  Memoranda  and  Formulae. 

"  This  excellent  little  work  is  admirably  adapted  to  fulfill  the  purpose  for  which  it  has  been  written.  It  is 
short,  clear,  and  eminently  practical.  The  author  is  evidently  an  accomplished  histologist,  and  his  book  conveys 
the  impression  that  it  is  based  upon  his  own  personal  experience." — The  LondoK  Medical  Record. 


p.  BLAKISTON,  SON  &=   CO:S 


GODLEE'S  ATLAS  OF  HUMAN  ANATOMY. 

Illustrating  most  of  the  Ordinary  Dissections  and  many  not  usually  practiced 
by  the  Student.  Accompanied  by  References  and  an  Explanatory  Text.  Com- 
plete. Folio  Size.  48  Colored  Plates.  By  Rickmax  John  Godlee,  m.d., 
F.R.c.S.  Forming  a  large  Folio  Volume,  with  References,  and  an  Octavo 
Volume  of  Letter-press. 

Price  of  the  two  Volumes,  Atlas  and  Letter-press,  Cloth,  $20.00 

"  It  is  likely  to  prove  as  useful  to  the  physician  and  ]  "  The  explanatory'  text  is  concise,  well  written,  and 
surgeon  as  to  the  anatomist." — Medical  Times  and  I  contains  many  valuable  suggestions  for  the  surgeon." 
Gazette.  |    — London  Lancet. 

GOWERS,  SPINAL  CORD. 

Diagnosis  of  Diseases  of  the  Spinal  Cord.  With  Colored  Plates  and  Engrav- 
ings. A  Second  Edition.  Revised  and  Enlarged.  By  William  R.  Gowers, 
M.D.,  Assistant  Professor  Clinical  Medicine,  University  College,  London.  8vo. 
Second  Edition.  Price  ^1.50 

BY   SAME  AUTHOR. 

OPHTHALMOSCOPY. 

A  Manual  and  Atlas  of  Medical  Ophthalmoscopy.  With  16  Colored  Auto" 
type  and  Lithographic  Plates  and  26  Wood  Cuts,  comprising  112  Original  Illus- 
trations of  the  Changes  in  the  Eye  in  Diseases  of  the  Brain,  Kidneys,  etc.    8vo. 

Price  $6.00 

EPILEPSY  AND  ITS  TREATMENT. 

Epilepsy  and  other  Chronic  Convulsive  Diseases  :  Their  Causes,  Symptoms, 
and  Treatment.     Octavo,      ynst  Ready.  Price,  Cloth,  $4.00 

NERVOUS  DISEASES. 

A  Manual  of  Diseases  of  the  Nervous  System,  for  Practitioners  and  Students. 

In  Press. 

"Dr.  Gowers,  while  profoundly  conversant  with  the  literature  of  his  subject,  has  not  allowed  himself  to  be 
influenced  to  an  undue  extent  by  the  writings  of  others,  but  while  fairly  stating  their  views,  where  this  is  neces- 
sary, he  at  the  same  time  brings  to  bear  upon  them  the  experience  derived  from  his  own  extensive  observations, 
and  when,  consequently,  they  receive  confirmr-,tion  or  not  at  his  hands,  they  are  all  the  more  valuable  as  being  the 
outcome  of  the  most  searching  and  unbiased  criticism.  It  would  be  impossible,  within  the  limits  of  a  short  re- 
view, to  convey  an  adequate  idea  of  the  extent  of  Dr.  Gowers"  work." — Edinburgh  Medical  journal. 

G»REENHOW,  BRONCHITIS. 

On  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphysema,  and 
Diseases  of  the  Heart.     By  E.  Headlam  Greenhow,  m.d.  i2mo.      Price  $1.50 

BY    S.A.ME   AUTHOR. 

ADDISON'S  DISEASE. 

Being  the  Croonian  Lectures,  delivered  before  the  Royal  College  of  Physi- 
cians, London.     Revised  and  Illustrated  by  Plates  and  Reports  of  Cases.     8vo. 

Price  $3.00 

"The  book  forms  a  most  interesting  and  valuable  monograph,  comprehensive  and  exhaustive." — British 
Medical  yournal. 

HUGHES,  COMPEND  OF  THE  PRACTICE  OF  MEDICINE. 

A  Compend  of  Practice.  By  Daniel  E.  Hughes,  m.d.,  Demonstrator  of 
Clinical  Medicine  at  Jefferson  l\Iedical  College,  Philadelphia.     In  two  parts — 

Part  I. — Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the  Stom- 
ach Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  etc.,  and  General 
Diseases,  etc. 

Part   II. — Diseases    of  the   Respiratory    System,    Circulatory    System,    andj 
Nervous  System  ;  Diseases  of  the  Blood,  etc. 
Price  of  each  Part,  in  Cloth,  $1.00;  interleaved  for  the  addition  of  Notes,  $1.25 

%*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice 
of  Medicine,  containing  the  Synonyms,  Definitions,  Causes,  Symptoms,  ProgI 
nosis.  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  including  a  number  of 
new  prescriptions.  They  have  been  compiled  from  the  lectures  of  prominent 
Professors,  and  reference  has  been  made  to  the  latest  writings  of  Professor^ 
■Flint,  Da  Costa,  Reynolds,  Bartholow,  Roberts  and  others. 


PUBLICA  TIONS. 


19 


HABERSHON,  ON  THE  STOMACH. 

On  Diseases  of  the  Stomach— The  Varieties  of  Dyspepsia — Their  Diagnosis 
and  Treatment.  By  S.  O.  Habershon,  m.d.,  f.r.c.p.,  Senior  Physician  to,  and 
Late  Lecturer  on,  the  Principles  and  Practice  of  Medicine  at  Guy's  Hospital. 
Third  Edition,  Revised.     Crown  8vo.  Price  ^1.25 

"As  an  expression  of  the  results  of  long  personal  experience  in  both  hospital  and  private  practice,  conveyed 
in  agreeable  though  not  always  perspicuous  diction,  this  contribution  of  Dr.  Habershon's  has  special  value  of  its 
own,  and  is  so  far  entitled  to  the  favorable  consideration  of  the  practitioner,  as  is  already  testified  by  a  demand 
for  a  third  edition." — American  yournal  of  Medical  Sciences. 

HALE,  ON  CHILDREN. 

The  Management  of  Children  in  Health  and  Disease.  A  Book  for  Mothers. 
By  Mrs.  Amie  M.  Hale,  m.d.  Abounding  in  valuable  information  and  com- 
mon sense  advice.     New  Enlarged  Edition.     i2mo.  Price  .75 

"  We  shall  use  our  influence  in  the  introduction  of  this  work  to  families  under  our  care,  and  we  urge  the  pro- 
fession generally  to  follow  our  example." — Buffalo  Medical  and  Surgical  yournal. 

HORWITZ,  COMPEND  OF  SURGERY. 

A  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Fractures, 
Ligatures,  Dislocations,  Surgical  Diseases,  etc.,  with  Differential  Diagnosis  and 
Treatment.     By  Orville  Horwitz,  b.s.,  m.d.,  with  Illustrations.  i2mo. 

Cloth,  $,\.QO 

HARDWICKE,  MEDICAL  EDUCATION. 

Medical  Education  and  Practice  in  All  Parts  of  the  World.  Containing 
Regulations  for  Graduation  at  the  Various  Universities  throughout  the  World. 
By  Herbert  Junius  Hardwicke,  m.d.,  m.r.c.p.     8vo.,  Price  $3.00 

"  Dr.  Hardwicke's  book  will  prove  a  valuable  source  of  information  to  those  who  may  desire  to  know  the 
conditions  upon  which  medicSl  practice  is  or  may  be  pursued  in  any  or  every  country  of  the  world,  even  to  the 
lemotest  corners  of  the  earth.  Thework  has  been  compiled  with  great  care,  and  must  have  required  a  vast, 
amount  of  labor  and  perseverance  on  the  part  of  its  author." — Dublin  Medical  yournal. 

HARLEY,  ON  THE  LIVER.     Illustrated. 

On  Diseases  of  the  Liver,  with  or  without  Jaundice.  Diagnosis  and  Treat- 
ment. By  George  Harley,  m.d.  Author  of  the  Urine  and  Its  Derangements. 
With  Colored  Plates  and  Numerous  Illustrations.     Royal  Octavo.  * 

Price,  Cloth,  $5.00  ;  Leather,  $6.00. 


"  It  is  one  of  the  freshest,  vtost  readable ,  and  most 
instructive  medical  books  that  have  been  laid  upon  our 
table  during  the  present  decade.  .  .  In  conclusion, 
we  commend  again  most  heartily  Dr.  Harley's 
extremely  valuable  book." — Philadelphia  Medical 
Times. 

"  The  work  is  far  in  advance,  in  original  and  prac- 
tical information,  of  any  treatise  on  the  subject  with 
rt'hich  we  are  acquainted,  and  is  worth  many  times  its 
cost  to  any  physician  treating  hepatic  troubles." — 
Chicago  Medical  Times. 


"  The  whole  subject-matter  is  treated  in  a  masterly 
manner,  and  the  work  is  destined  to  find  a  place 
among  the  classics." — Medical  Herald,  Louisville , 
Ky. 

"  It  is  the  outcome  of  a  mind  that  went  to  its  task 
amply  equipped  therefor.  It  is  the  product  of  long 
thinking  and  ripe  judgment.  .  .  .  We  must  con- 
tent ourselves  with  this  bare  statement,  hoping  that 
those  who  read  the  book  will  derive  as  much  benefit  as 
ourselves." — JVew  Orleans  Medical  and  Surgical 
yournal. 


HOLDEN,  HUMAN  OSTEOLOGY.     Sixth  Edition. 

Comprising  a  Description  of  the  Bones,  with  Colored  Delineations  of  the  At- 
tachments of  the  Muscles.  The  General  and  Microscopical  Structure  of  Bone 
and  its  Development.  By  the  Author  and  A.  Doran,  f.r.c.s.,  with  Lithographic 
Plates,  etc.  By  Luther  Holden,  f.r.c.s.  Numerous  Illustrations.  Sixth 
Edition,  carefully  Revised,  Price  $6.00 

BY   SAME   author. 

ANATOMY. 

Manual  of  Dissections  of  the  Human  Body.  Fourth  London  Edition.  With 
170  Illustrations.  Price  $5.50 

LANDMARKS. 

Landmarks,  Medical  and  Surgical,  Third  London  Edition.  Revised  and 
Enlarged.  Price  5]ii. 00 

"Mr.  Holden  is  the  happy  possessor  of  the  faculty  of  writing  interesting  works  on  Anatomy.  A  part  of  the 
charm  consists  in  the  frequent  references  to  practical  points,  and  in  the  explanation  of  the  advantages  ail'  objects 
of  details  of  structures." — Boston  Medical  and  Surgical  yournal. 


20  P.  BLAKISTON,  SON  &^  CO.'S 

HEATH'S  OPERATIVE  SURGERY. 

A  Course  of  Operative  Surgery,  consisting  of  a  Series  of  Plates,  feach  plate 
containing  Numerous  Figures,  Drawn  from  Nature  by  the  Celebrated  Anatomi- 
cal Artist,  M.  Leveille,  of  Paris,  Engraved  on  Steel  and  Calored  by  Hand, 
under  his  immediate  superintendence,  with  Descriptive  Text  of  Each  Operation. 
By  Christopher  Heath,  f.r.c.s.,  Surgeon  to  University  College  Hospital,  and 
Holme  Professor  of  Clinical  Surgery  in  University  College,  London.  One  Large 
Quarto  Volume.  Price  $14.00 

The  author  has  embodied  in  this  work  the  experience  gained  by  him  during 
tiventy  years  of  surgical  teaching.  It  comprises  all  the  operations  that  are  required 
in  ordinary  surgical  practice.  He  has  selected  for  illustration  and  description  those 
methods  which  appear  to  give  the  best  results  in  practice,  referring  to  the  errors 
likely  to  occur  and  the  best  methods  of  avoiding  them. 

BY   SAME   AUTHOR. 

THE   STUDENT'S  GUIDE  TO  SURGICAL   DIAGNOSIS. 

i.imo.  Price  §1.25 

"  Mr.  Heath  is  so  well  known,  both  as  a  practical  surgeon,  teacher  and  writer,  that  anything  from  his  pen  re- 
quires no  introduction  from  the  hands  of  reviewers,  and  scarcely  any  notice  but  the  announcement  of  the  fact  that 
he  has  written  a  book." — Medical  Record. 

A  MANUAL  OF    MINOR    SURGERY   AND   BANDAGING. 

Sixth    Edition,    Revised    and   Enlarged.      With    115    Illustrations.       i2mo. 

Price  |2.oo 

"This  excellent  work  should  not  be  termed  a  '  Minor'  Surgery,  but  it  really  consists  of  the  sum  and  substance 
of  Practical  surgerj'.     We  would  not  exchange  it  for  any  book  in  our  possession." — Scuthern  Clinic. 

HEATH'S  PRACTICAL  ANATOMY.     Fifth  London  Edition. 

Practical  Anatomy.  A  Manual  of  Dissections.  Fifth  London  Edition.  24 
Colored  Plates,  and  nearly  300  other  Illustrations.     Just  Ready.  Price  I5.00 

INJURIES  AND  DISEASES  OF  THE  JAWS. 

The  Jacksonian  Prize  Essay  of  the  Royal  College  of  Surgeons  of  England, 
1*867.     Second  Edition,  Revised,  with   over   150  Illustrations.     Octavo. 

Price  14-25 
HOOD,  ON  GOUT  AND  RHEUMATISM. 

A  Treatise  on  Gout,  Rheumatism,  and  the  Alhed  Affections.  Their  Treat- 
ment, Complications,  and  Prevention.  By  Peter  Hood,  m.d.  Second  Edi- 
tion, Revised  and  Enlarged.     With  some  Considerations  on  Longevity.  Octavo. 

Price  $3.50 

"  The  Observations  on  Treatment  are  specially  to  be  commended." — London  Lancet. 

HOLDEN,  THE  SPHYGMOGRAPH. 

The  Sphvgmograph.  Its  Physiological  and  Pathological  Indications.  By 
Edgar  Holden,  m.d.  Illustrated  by  Three  Hundred  Engravings  on  Wood. 
8vo.  Price  $2.00 

HOLMES,  THE  LARYNGOSCOPE. 

A  Guide  to  the  Use  of  the  Laryngoscope  in  General  Practice.  By  Gordon 
Holmes,  m.d..  Physician  to  the  Throat  and  Ear  Infirmary.     i2mo.     Price  |i.oo 

BY   SAME   AUTHOR. 

VOCAL  PHYSIOLOGY. 

Vocal  Physiology  and  Hygiene.  With  reference  to  the  Cultivation  and 
Preservation  of  the  Voice.     Illustrated.     i2mo.  Price  ;g2. 00 

HOFF,  ON  HEMATURIA. 

Hcematuria  as  a  Symptom  of  the  Diseases  of  the  Genito-Urinary  Organs.  By 
O.  HoFF,  m.d.     Illustrated.     i2mo.  Price  .75 


PUB  Lie  A  TIONS. 


HUNTER,  MECHANICAL  DENTISTRY. 

A  Practical  Treatise  on  the  Construction  of  the  Various  kinds  of  Artificial 
Dentures,  with  Formulae,  Receipts,  etc.  By  Charles  Hunter,  d.d.s.  igo 
Illustrations.     i2mo.  Price  ^r.50 

"  It  is  the  outcome  of  his  own  experience  of  some  twenty  years  as  a  Mechanical  Dentist,  and  contains,  moreover, 
much  derived  from  practical  knowledge  of  other  dentists.  The  value  of  the  book  is  also  much  added  to  by  illus- 
trations. It  will  be  very  useful  to  the  Dental  Student,  and  to  all  Mechanical  Dentists." — London  Medical  Times 
4.nd  Gazette. 

HUTCHINSON'S    ILLUSTRATIONS    OF    CLINICAL   SUR- 
GERY.    First  Volume  Complete. 

Consisting  of  Plates,  Photographs,  Woodcuts,  Diagrams,  etc.  Illustrating 
Surgical  Diseases,  Symptoms,  and  Accidents;  also  Operations  and  other 
Methods  of  Treatment.  With  Descriptive  Letter-press.  By  Jonathan  Hutch- 
inson, F.R.C.S.,  Senior  Surgeon  to  the  London  Hospital,  Surgeon  to  the  Moor- 
fields  Ophthalmic  Hospital,  and  to  the  Hospital  for  Diseases  of  the  Skin,  Black- 
friars.  In  Quarterly  Fasciculi.  Imperial  4to.  Volume  i.  (Ten  Fasciculi)  bound 
complete  in  itself.  Price  $25.00.  Parts  Eleven  to  Fifteen  of  Volume  2,  Now- 
Ready.  Each,  $2.50 

HEWITT,  DISEASES  OF  WOMEN.     Fourth  Edition. 

The  Diagnosis,  Pathology,  and  Treatment  of  Diseases  of  Women,  Including 
the  Diagnosis  of  Pregnancy.  Founded  on  a  Course  of  Lectures  Delivered  at  St. 
Mary's  Hospital  Medical  School.  By  Graily  Hewitt,  m.d.,  Lond.,  m.r.c.p., 
Physician  to  the  British  Lying-in  Hospital ;  Lecturer  on  Midwifery  and  Diseases 
of  Women  and  Children  at  St.  Mary's  Hospital  Medical  School;  Honorary 
Secretary  to  the  Obstetrical  Society  of  London,  etc.  The  Fourth  American 
Edition.     Revised  and  Enlarged,  with  New  Illustrations.     Octavo. 

Price,  Paper,  IS1.50;  Cloth,  $2.50 


"  Readers  of  the  former  editions  will  not  require  to 
be  told  that  the  additions  now  made  are  of  the  highest 
possible  excellence." — Titnes  and  Gazette. 

"  It  is  one  of  the  most  useful,  practical,  and  compre- 
hensive works  upon  the  subject  in  the  English  language, 
a  true  guide  to  the  student,  and  an  invaluable  means  of 
reference  for  the  teacher." — N.  Y.  Medical  Record. 


"  The  excellent  work  of  Dr.  Hewitt  presents — in  a 
form  well  adapted  to  conduct  the  student  to  a  knowledge 
of  the  Diseases  of  Women,  and  to  assist  the  young 
practitioner  in  his  study  of  these  diseases  at  the  bedside 
of  the  patient — a  very  full  and  clear  exposition  of  the 
views  entertained  by  the  most  authoritative  teachers  as 
to  their  pathological  treatment  and  their  correct  Diag- 
nosis."— Amer.  Med.  jfournal. 

HAY,  SARCOMATOUS  TUMOR. 

History  of  a  Case  of  Recurring  Sarcomatous  Tumor  of  the  Orbit  in  a  Child. 
By  Thomas  Hay,  m.d.     Illustrated.     Paper.  Price  .50 

HEWSON,  EARTH  IN  SURGERY. 

Earth  as  a  Topical  Application  in  Surgery,  Being  a  Full  Exposition  of  its  Use 
In  Cases  Requiring  Topical  Applications.  By  Addinell  Hewson,  m.d.  Illus- 
trated.   8vo.  Price  $2.50 

HODGE,  ON  ABORTION. 

On  Foeticide  or  Criminal  Abortion.     By  Hugh  L.  Hodge,  m.d. 

Price,  Paper,  .30;  Cloth,  .50 
HODGE,  CASE-BOOK. 

Note-Book  for  Cases  of  Ovarian  Tumors.  By  H.  Lennox  Hodge,  m.d.  With 
Diagrams.  Price,  Paper,  .50 

HIGGINS,  DISEASES  OF  THE  EYE.     Now  Ready. 

A  Hand-Book  of  Ophthalmic  Practice.  By  Charles  Higgins,  f.r.c.s. 
Ophthalmic  Assistant  Surgeon    at  Guy's   Hospital.      Second  Edition.      i6mo. 

Price  .50 

Contents. — Section  i.  Discharge  from  the  Eyes.  ii.  Intolerance  of  Light,  iii.  Iritis  and  Glaucoma,  iv. 
Diseases  of  the  Eyelids,  v.  Watering  of  the  Eye.  vi.  Acuteness  of  Vision,  Field  of  Vision,  Anomalies  of  Re- 
fraction, Astigmatism,  Accommodation,  Presbyopia,  vii.  Disturbance  of  Vision,  Use  of  the  Ophthalmoscope; 
Normal  and  Morbid  Appearances,     vm.  Injuries. 

"We  have  rarely  seen  so  much  important  information  condensed  in  so  short  a  space." — American  Medical 
journal. 


22  P.  BLAKISTON,  SON  &-  CO.'S 

HARRIS,  THE  PRACTICE  OF  DENTISTRY.     Tenth  Edition. 

The  Principles  and  Practice  of  Dentistry.  Tenth  Revised  Edition.  In  great 
part  Rewritten,  Rearranged,  and  with  many  new  and  important  Illustrations. 
By  Chapin  a.  Harris,  m.d.,  d.d.s.  Edited  by  P.  H.  Austen,  m.d..  Professor 
of  Dental  Science  and  Mechanism  in  the  Baltimore  College  of  Dental  Surgery. 
With  nearly  400  Illustrations.     Royal  Octavo.    Price,  Cloth,  ^6.50 ;  Leather,  I7.50 

This  new  edition  of  Dr.  Harris'  work  has  been  thoroughly  revised  in  all  its  parts, 
more  so  than  any  previous  edition.  So  great  have  been  the  advances  in  many 
branches  of  dentistry  that  it  was  found  necessary  to  rewrite  the  articles  or  subjects, 
and  this  has  been  done  in  the  most  efficient  manner  by.  Professor  Austen,  for  many 
years  an  associate  and  friend  of  Dr.  Harris,  assisted  by  Professor  Gorgas  and  Thomas 
S.  Latimer,  m.d.  The  publishers  feel  assured  that  it  will  now  be  found  the  most 
complete  text-book  for  the  student,  and  guide  for  the  practitioner  in  the  Enghsh 
language. 

BY    SAME  AUTHOR. 

MEDICAL  AND  DENTAL  DICTIONARY.     Fourth  Edition. 

A  Dictionary  of  Medical  Terminology,  Dental  Surgery,  and  the  Collateral 
Sciences.  Fourth  Edition,  Carefully  Revised  and  Enlarged.  By  Ferdinand 
J.  S.  Gorgas,  M.D. ,  d.d.s.,  Professor  of  Dental  Surgery  in  the  Baltimore  College, 
etc.     Royal  Octavo,  Price,  Cloth,  $6.50;  Leather,  $7.50 

This  Dictionary,  having  passed  through  tAree  editions,  and  been  for  some  time 
out  of  print,  has  been  again  carefully  revised  by  F.  J.  S.  Gorgas,  m.d..  Dr.  Harris" 
successor  as  Professor  of  Dental  Surgery  in  the  Baltimore  College  of  Dental  Surgery. 
In  his  preface  to  this  new  edition,  the  editor  says  : — 

"  The  object  of  the  reviser  has  been  to  bring  the  book  thoroughly  up  to  the  pres- 
ent requirements  of  the  profession,  the  Medical  portion  having  been  as  carefully  re- 
vised and  added  to  as  that  devoted  more  especially  to  Dental  Science,  while  a 
number  of  obsolete  terms  and  methods  have  been  omitted.  In  nearly  every  one  of 
the  seven  hundred  and  forty-three  pages  of  the  former  edition  corrections  and  addi- 
tions have  been  made,  and  many  new  processes,  terms  and  appliances  described, 
some  of  which  are  not  found  in  any  other  work  published." 

HANDY,  ANATOMY. 

Text-Book  of  Anatomy  and  Guide  to  Dissections.  For  the  Use  of  Students. 
By  W.  R.  Handy,  m.d.     312  Illustrations.  Price  S3.00 

HILLIER,  DISEASES  OF  CHILDREN. 

A  Clinical  Treatise  on  the  Diseases  of  Children.  By  Thomas  Hillier,  m.d. 
8vo.  Price  $2.00. 

HUFELAND,  LONG  LIFE. 

The  Art  of  Prolonging  Life.  By  C.  W.  Hufeland.  Edited  by  Erasmus 
Wilson,  m.d.     i2mo.  Price  $1.00 

"  We  wish  all  doctors  and  all  their  intelligent  clients  would  read  it,  for  surely  its  perusal  would  be  attended 
-A'ith  pleasure  and  benefit." — American  Practitioner. 

"  It  certainly  should  be  in  the  library  of  every  physician." — Medical  Brie/. 

HUNTER,  PORTRAIT  OF. 

Portrait  of  John  Hunter.  From  Sharp's  well-known  Engraving ;  a  copy  of 
Sir  Joshua  Reynold's  Portrait.  For  Framing.  Large  size,  9x11;  sheet  16  x20. 
Price,  in  the  Sheet,    sent  free  by  mail,   50   cents  ;    or,  Handsomely   Framed^ 

Price  ;fS2.oo 


PUBLICA  TIONS.  33 


HEADLAND,  THE  ACTION  OF  MEDICINES.       Ninth  Edition. 

On  the  Action  of  Medicines  in  the  System.  By  F.  W.  Headland,  m.d. 
Ninth   American  Edition,  Revised  and  Enlarged.    8vo.  Price  $3.00 

"  It  displays  in  every  page  the  evidence  of  extensive  knowledge  and  of  sound  reasoning;  it  will  be  useful  alite 
to  those  who  are  just  commencing  their  studies,  and  to  those  who  are  engaged  in  the  active  pursuits  of  pro- 
fessional life." — Medical  Times. 

"  The  very  favorable  opinion  which  we  were  amongst  the  first  to  pronounce  upon  this  essay  has  been  fully 
confirmed  by  the  general  voice  of  the  profession,  and  Dr.  Headland  may  now  be  congratulated  on  having  pro- 
duced a  treatise  which  has  been  weighed  in  the  balance,  and  found  worthy  of  being  ranked  with  our  standard 
medical  works." — London  Lancet. 

JAMES,  SORE  THROAT. 

On  Sore  Throat,  Its  Nature,  Varieties  and  Treatment,  Including  its  Con- 
nection with  other  Diseases.  By  Prosser  James,  m.r.c.p.  Fourth  Edition, 
Revised  and  Enlarged.     With  Colored  Plates  and  Numerous  Wood-cuts.     i2mo. 

Price  $1.25 

"  We  can  confidently  recommend  his  therapeutic  teachings  as  well  worthy  of  the  careful  consideration  of  the 
Profession,  for  they  set  forth  the  practice  of  an  enthusiastic  worker,  whose  special  experience  has  been  large  and 
lengthened." — British  Medical  yournal. 

"  The  practitioner  who  buys  Dr.  James'  unpretending  little  book  will  provide  himself  with  a  wise  and  practical 
clinical  commentary,  and  with  a  well  arranged  digest  of  long  and  varied  experience." — IVestnzinster  Meview. 

BY   SAME   AUTHOR. 

LARYNGOSCOPY  AND  RHINOSCOPY. 

Including  the  Diagnosis  of  Diseases  of  the  Throat  and  Nose.  Third  Edition. 
With  Colored  Plates.     i8mo.  Price  $2.00. 

"  It  gives  in  a  succinct  form  the  approved  methods  of  examination  and  treatmen  t  of  diseases  of  the  nose,  throat, 
and  larynx.  The  plan  pursued  is  one  well  adapted  to  the  needs  of  the  general  practitioner." — American  Medical 
yournal. 

JONES,  AURAL  ATLAS. 

An  Atlas  of  Diseases  of  the  Membrana  Tympani.  Being  a  Series  of  Colored 
Plates,  containing  62  Figures.  With  appropriate  Letter-press  and  Explanatory 
Text.  By  H.  Macnaughton  Jones,  m.d.,  Surgeon  to  the  Cork  Ophthalmic  and 
Aural  Hospital.     4to.  Price  ^4.00. 

"  The  cases  are  well  selected,  the  drawings  executed  from  life,  highly  artistic  and  very  conscientious,  and  the 
commentaries  indicate  familiarity  with  the  subject  and  good  judgment  in  dealing  with  it." — British  Medical 
yournal. 

BY   SAME    AUTHOR. 

AURAL  SURGERY. 

A  Practical  Hand-book  on  Aural  Surgery.  Illustrated. '  Second  Edition,  Re- 
vised and  Enlarged,  with  new  Wood  Engravings.     i2mo.     Cloth.       Price  $2.75 

JONES,  SIEVEKING  AND  PAYNE,  PATHOLOGICAL  AN- 
ATOMY. 

A  Manual  of  Pathological  Anatomy.  By  C.  Handfield  Jones,  m.d.,  and 
Edvitard  H,  Sieveking.  m.d.,  Physician  to  St.  Mary's  Hospital,  A  New  En- 
larged Edition.  Edited  by  J.  F.  Payne,  m.d.,  Lecturer  on  Morbid  Anatomy  at 
St.  Thomas'  Hospital.     With  Numerous  Illustrations.     Demi  8vo.     Price  $5.50. 

JONES,  ON  SIGHT  AND  HEARING. 

The  Defects  of  Sight  and  Hearing,  their  Nature,  Causes,  and  Prevention.  By 
T.  Wharton  Jones,  m.d.     Second  Edition.     i6mo.  Price  .50. 

KIRBY,  ON  PHOSPHORUS.     Fifth  Edition. 

Phosphorus  as  a  Remedy  for  Functional  Diseases  of  the  Nervous  System. 
By  E.  A.  KiRBY,  m.d.     Fifth  Edition.     8vo.  Price  ;^i.oo 

KOLLMEYER,  KEY  TO  CHEMISTRY. 

Chemia  Coartata,  or  Key  to  Modern  Chemistry.  By  A.  H.  Kollmeyer,  m.d. 
With  Numerous  Tables,  Tests,  etc.  Price  $2.35 

KIRKE,  PHYSIOLOGY.     Revised  and  Enlarged. 

A  Hand-book  of  Physiology.  By  Kirke.  Tenth  London  Edition.  By  W 
MoRRANT  Baker,  m.d.     420  Illustrations.     Now  Ready.  Price  $5.00 

"  This  is  undoubtedly  the  best  work  for  students  on  Physiology  extant." — Cincinnati  Med.  News. 


24  p.  BLAKISTON,  SON  &^   CO.'S 

KANE,  THE  OPIUM,  MORPHINE  AND  SIMILAR  HABITS. 

Drugs  that  Enslave.  The  Opium,  Morphine,  Chloral,  Hashisch  and  Similar 
Habits.    By  H.  H.  Kane,  m.d.,  of  New  York.     With  Illustrations.     Price  I1.25. 

"  It  contains  a  large  amount  of  information  collected  with  much  labor  and  presented  In  a  systematic  manner. 
The  subject  of  the  chloral  habit  has  not  been  investigated  by  any  one,  we  believe,  so  thoroughly  as  Dy  Dr.  Kane." 
— Medical  Record. 

"  It  deserves  to  be  raad  by  those  who  feel  an  interest  in  discouraging  the  use  of  these  dangerous  drugs.  The 
book  is  embellished  by  an  excellent  phototype  frontispiece  of  Laocoon." — American  yournal  of  Pliar»tcu:y. 

"A  work  of  more  than  ordinary  ability  and  careful  research.  .  .  .  For  the  first  time,  reliable  statistics  on 
the  use  of  chloral  are  classified  and  published,  .  .  .  and  it  is  shown  that  the  use  of  c^orsX^  causes  a  more 
complete  and  rapid  ruin  oftnitid  and  body  than  either  opium  or  morphine." — Druggists'  Circular  and  Gazette.- 

KIDD,  THERAPEUTICS. 

The  Laws  of  Therapeutics ;  or,  the  Science  and  Art  of  Medicine.  By  Joseph 
KiDD.  M.D.     i2mo.     Cloth.  Price  ^1.25. 

"  Dr.  Kidd  acknowledges  two  laws — that  oi  contraria  contrariis  and  similia  similibus  ;  but  the  cases  he  giTes 
in  his  chapter  on  ars  7nedica  show  that,  like  a  sensible  practitioner,  he  does  not  allow  himself  blindly  to  follow 
either  the  one  or  the  other,  but  seeks  out  the  cause  of  disease,  and  tries  by  rational  measures  to  remove  it.  The 
cases  are  the  most  valuable  part  of  the  book." — London  Practitioner . 

LANDIS,  A  COMPEND  OF  OBSTETRICS.     Illustrated. 

A  Compend  of  Obstetrics ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  Henry  G.  Landis,  m.d..  Professor  of  Obstetrics  and  Diseases 
of  Women  in  Starling  Medical  College,  Columbus,  Ohio.  Illustrated.  12 mo. 
Cloth.  Price  gi.oo;  interleaved  for  the  addition  of  Notes,  $1.25 


"  The  questions  are  well  chosen,  the  answers  clear, 
concise,  and  well  up  to  the  present  state  of  obstetrical 
science.  It  v.-ill  be  a  handy  book  for  reference  for 
practitioner   as   well    as    student." — Prof.   E.    O.   P. 


"  It  is  complete,  accurate  and  scientific  ;  the  very 
best  book  of  its  kind." — Pro/,  jf.  S.  Knox,  Rush 
Medical  College,  Chicago. 

"  I  have  been  teaching  in  this  department  for  many 


Roler,  Chicago  Medical  College.  years,  and  am  free  to  say  that   this  will   be  the  best 

"  I  have  observed  no  statement  to  the  correctness  assistant  I  ever  had.     It  is  accurate  and  comprehen- 

of  which  I  could  take  exception.     There  are  very  few  sive,  but  brief  and  pointed." — Prof.  P.  D.    Yost,  St. 

practitioners  who  cannot  be  instructed  by  its  perusal."  |    Louis. 
—David  Wark,  31.  D.,   U.   S.  Medical  College,  New 

York.  \ 

LEGG,  ON  THE  URINE. 

Practical  Guide  to  the  Examination  of  the  Urine,  for  Practitioner  and  Student. 
By  J.  WiCKHAM  Legg,  m.d.     Fifth  Edition,  Enlarged.     Illustrated.     i2mo. 

Price  .75 

This  little  work  is  intended  to  supply  the  Physician  or  Student  with  a  concise  guide 

to  the  recognition  of  the  different  characteristics  of  the  urine,  and  though  small  and 

well  adapted  to  the  pocket,  contains,  probably,   everything  that  could  be  gleaned 

from  a  larger  work. 

LEARED,  IMPERFECT  DIGESTION. 

The  Causes  and  Treatment  of  Imperfect  Digestion.  By  Arthur  Leared,  M.d. 
The    7th    Edition.     Revised  and  Enlarged.     i2mo.  Price  $2.00 

LIEBREICH,  ATLAS  OF  OPHTHALMOSCOPY. 

An  Atlas  of  Ophthalmoscopy,  containing  12  Full-page  Chromo-Lithographic 
Plates,  with  59  Figures.  By  R.  Liebreich,  m.d.  Second  Edition,  Enlarged. 
Large  Quarto.  Price  ^12.00 

LIVEING,  ON  SICK  HEADACHE. 

Megrim,  or  Sick  Headache  and  Some  Allied  Disorders.  By  Edward  Live- 
ING,  M.D.     With  Plates.  Tables,  etc.     8vo.  Price  $5.50 

LEBER  AND  ROTTENSTEIN,  DENTAL  CARIES. 

Dental  Caries  and  Its  Causes.     An  Investigation  into  the  Influence  of  Fungi 

-  in  the  Destruction  of  the  Teeth.    By  Drs.  Leber  and  Rottenstein.    Illustrated. 

8vo.  Paper  Cover  75  cents  ;    Cloth,  $1.25 

"  The  work  gives  the  result  of  patient  observation,  presents  the  deductions  of  its  authors  with  a  perspicuity  and 
modesty  calculated  to  secure  for  its  positions  a  thoughtful  consideration.  We  heartily  commend  it  a*  an  educa. 
tional  work." — Dental  Cosmos. 


PUB  Lie  A  TIONS. 


25 


I.EWIN,  ON  SYPHILIS. 

The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of  Berlin.  Translated 
by  Carl  Proegler,  m.d.,  and  E.  H.  Gale,  m.d.,  Surgeons  U.  S.  Army.  Illus- 
trated.    i2mo.  Price  $1.25 

"  When  such  authorities  as  Dr.  Drysdale  (as  we  quoted  a  few  weeks  ago)  condemn  the  use  of  mercury  in  syphilis 
as  "  too  dangerous,"  while,  on  the  other  hand,  eminent  surgeons,  such  as  Professor  Gross,  will  not  treat  a  case 
without  that  drug,  general  practitioners  will  gladly  welcome  any  media  via  which  gives  us  all  the  good  effects  of 

mercurials  without  any  danger  of  their   ill  results  appearing.     This  is  what  is  accomplished  by  Dr.  Lewin." 

Philadelphia  Medical  a7id  Surgical  Reporter. 

LIZARS,  ON  TOBACCO. 

The  Use  and  Abuse  of  Tobacco.     By  John  Lizars,  m.d.  i2mo. 

LONGLEY,   POCKET  MEDICAL  LEXICON. 

Students'  Pocket  Medical  Dictionary,  Giving  the  Correct  Definition  and  Pro^ 
nunciation  of  all  Words  and  Terms  in  General  Use  in  Medicine  and  the  Collate- 
ral Sciences,  with  an  Appendix,  containing  Poisons  and  their  Antidotes,  Abbre- 
viations Used  in  Prescriptions,  and  a  Metric  Scale  of  Doses.  By  Elias  Longley. 
24mo.  Price,  Cloth,  #1.00;  Tucks  and  Pocket  $1.25 

This  is  an  entirely  new  Medical  Dictionary,  containing  some  300  compactly 
printed  24mo  pages,  very  carefully  prepared  by  the  author,  who  has  had  much  ex- 
perience in  the  preparation  of  similar  works,  assisted  by  the  Professors  of  Chemistry 
and  of  Botany  in  one  of  our  leading  medical  colleges. 

"  It  is,  we  believe,  also  the  only  lexicon  in  existence 
in  which  the  pronunciation  of  words  is  fully  and  dis- 
tinctly marked." — Canada  Medical  Review. 

"  This  is  a  very  compact  and  complete  little  diction- 
ary. We  commend  it  as  particularly  useful  to  students." 
— N'eiv  York  Medical  journal. 


"  This  little  book  will  be  welcomed  by  students  in 
medicine  and  pharmacy  as  a  convenient  pocket  com- 
panion, giving  the  pronunciation,  acceptation,  and 
definition  of  medical,  pharmaceutical,  chemical  and 
botanical  terms." — Atnerican  yournal  of  Phartnacy. 

"  It  would  seem  to  be  just  the  book  for  dental  and 
medical  students." — Dental  Advertiser. 


MAYNE,  MEDICAL  DICTIONARY.     Fifth  Edition. 

A  Medical  Vocabulary,  Being  an  Explanation  of  all  Terms  and  Phrases  used 
in  the  Various  Departments  of  Medical  Science  and  Practice,  Giving  their  Deri- 
vation, Meaning,  Application,  and  Pronunciation.  Intended  specially  as  a  Book 
of  Reference  for  the  Student.  By  Drs.  R.  G.  and  J.  Mayne.  Fifth  Edition. 
Revised  and  Enlarged.     Cloth.     .  Price  ^4.00 

THE  POLYCLINIC. 

A  Monthly  Journal  of  Medicine  and  Surgery,  conducted  by  the  Faculty  of 
the  Philadelphia  Polyclinic  and  School  for  Graduates  in  Medicine.  Sample 
copies  free.  Terms,  per  Annum,  |i.oo 

An  invaluable  Monthly  Reference  List  for  Librarians,  Professors,  Specialists,  and 
all  wishing  to  keep  acquainted  with  the  Medical  Literature  of  the  day. 

MACDONALD,      MICROSCOPICAL      EXAMINATION      OF 
WATER. 

A  Guide  to  the  Microscopical  Examination  of  Drinking  Water.  By  J.  Do 
Macdonald,  m.d.  With  Twenty  Full-page  Lithographic  Plates,  Reference 
Tables,  etc.     8vo.  Price  ^^2.75 

"  The  volume  is  an  excellent  Aand-book  and  will  greatly  facilitate  the  study  of  the  sviVyftQX.."^— Popular  Science 
Monthly. 

yiPCl'S,,  THE  THERAPEUTIC  FORCES; 

Or,  The  Action  of  Medicine  in  the  Light  of  the  Doctrine  of  Conservation  of 
Force.     By  Thomas  J.  Mays,  m.d.     i2mo.  Price  #1.25 


26  p.  BLAKISTON,  SON  <S-   CO:S 


MACKENZIE,  ON  THE  THROAT  AND  NOSE. 

Including  the  Pharynx,  Larynx,  Trachea,  (Esophagus,  Nasal  Cavities,  and 
Neck.  By  Morell  Mackenzie,  m.d.,  London,  Senior  Physician  to  the  Hos- 
pital for  Diseases  of  the  Chest  and  Throat,  Lecturer  on  Diseases  of  the  Throat 
at  London  Hospital  Medical  College,  etc.,  etc. 

Vol.  L     Including  the  Pharynx,  Larynx,  Trachea,  etc.     112  Illustrations. 

Now  Ready.  Price,  Cloth,  $4.00 ;  Leather,  $5.00 

Vol.  II.     Including  the  (Esophagus,  Nasal  Cavities,  Neck,  etc.     Illustrated. 

In  Preparation. 
Author's  Edition,  issued  under  his  supervision,  containing  all  the  original  Wood 
Engravings,  and  the  essay  on  "  Diphtheria,  Its  Causes,  Nature,  and  Treatment,"  for- 
merly published  separately.  Each  volume  sold  separately ;  purchasers  of  Volume  I. 
will  receive  early  information  of  date  of  issue  and  price  of  Volume  II.,  upon  sending 
their  address  to  the  publishers. 

"We  have  long  felt  the  want  of  a  thoroughly  practical  and  systeniatic  treatise  on  diseases  of  the  throat 
and  nasal  passages.  Admirable  essays  have  from  time  to  time  appeared ;  no  standard  work  has  been  written. 
Any  one  familiar  with  laryngoscopic  work  must  appreciate  the  valuable  addition  now  made  to  this  special 
department  in  the  work  before  us.  The  entire  work  will  include  the  consideration  of  affections  of  the  pharynx, 
larynx,  trachea,  oesophagus,  nasal  cavities,  and  neck.  The  matter  now  presented  complete  for  the  first  time  is^ 
the  result  of  the  author's  large  and  unrivaled  experience,  both  in  hospital  and  private  practice,  extending  over 
a  period  of  twenty  years.  There  can  be  but  one  verdict  of  the  profession  on  this  manual — it  stands  without  any 
competitor  in  medical  literature,  as  a  standard  work  on  the  organs  it  professes  to  treat  of." — Dublin  Journal. 

"  It  is  both  practical  and  learned  ;  abundantly  and  well  illustrated  ;  its  descriptions  of  disease  are  graphic,  and 
the  diagnoses  the  best  we  have  anywhere  seen.  To  give  examples  of  the  thoroughness  of  Dr.  Mackenzie's  book, 
we  may  cite  the  chapter  on  diphtheria,  which  embraces  47  pages.  The  chapter  on  non-malignant  tumors  of  the 
larynx  would  appear  to  be  absolutely  e.xhaustive.  Nowhere  else  have  we  seen  so  elaborate  a  statement  of  the  sub- 
ject. We  can  predict  for  this  work  a  high  position,  and  congratulate  its  distinguished  author  upon  its  appear- 
ance."— FhiladelJ>hia  Medical  Times. 

BY   SAME   AUTHOR. 

THE  PHARMACOPOEIA  of  the   Hospital   for  Diseases   of  the 
Throat  and  Nose. 

The  Fourth  Edition,  much  enlarged,  containing  250  Formulae,  with  Directions 
for  their  Preparation  and  Use.     i6mo.  Price  $1.25 

GROWTHS  IN  THE  LARYNX. 

Their  History,  Causes,  Symptoms,  etc.  With  Reports  and  Analysis  of  one 
Hundred  Cases.     With  Colored  and  Other  Illustrations.     8vo.  Price  $2.00 

MACNAMARA,  DISEASES  OF  THE  EYE. 

A  Manual  of  the  Diseases  of  the  Eye.  By  C.  Macnamara,  m.d.  Fourth 
Edition,  Carefully  Revised ;  with  Additions  and  Numerous  Colored  Plates,  Dia- 
grams of  Eye,  Wood-cuts,  and  Test  Types.     Demi  8vo.  Price  $4.00 

"As  a  book  of  ready  reference  on  diseases  of  the  eye  it  has  no  superior,  and  we  may  safely  say,  no  equal  in  our 
language." — Cincinnati  Lancet  and  Observer. 

BY   SAME   AUTHOR. 

ON  THE  BONES  AND  JOINTS. 

Lectures  on  Diseases  of  the  Bones  and  Joints.     Second  Edition.      Demi  8vo. 

Price  $4.25 

MADDEN,   HEALTH    RESORTS. 

Health  Resorts  for  the  Treatment  of  Chronic  Diseases.  A  Hand-Book,  the 
result  of  the  author's  own  observations  during  several  years  of  health  travel  in 
many  lands,  containing  also  remarks  on  climatology  and  the  use  of  mineral 
waters.     By  T.  M.  Madden,  m.d.     8vo.  .Price  ^2.50 

"  Rarely  have  we  encountered  a  book  containing  so  much  information  for  both  invalids  and  pleasure  seekers." 
—  The  Sanitarian. 

MEDICAL  REGISTER. 

Directory  of  Physicians  in  Philadelphia.     Octavo.  New  Editio7i  in  Press. 


PUBLICA  TIONS.  rj 


MARSHAjLL  &  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  John  Marshall,  m.d.,  and  Edgar 
F.  Smith,  m.d.,  of  the  Chemical  Laboratory,  Medical  Department,  University  of 
Pennsylvania.     Illustrated  by  Phototype  Plates.  l2mo.  Price  ;^i.oo 

MARSHALL,  ANATOMICAL  PLATES; 

Or  Physiological  Diagrams.     Life  Size  (7  by  4  feet)  and  Beautifully  Colored. 
By  John  Marshall,  f.r.s.     An  Entirely  New  Edition,  Revised  and  Improved, 
Illustrating  the  Whole  Human  Body. 
The  Set,  Eleven  Maps,  in  Sheets,  Price  ^50.00 

"  "  handsomely  Mounted  on  Canvas,  with 

Rollers,  and  Varnished,  Price  $80.00 
An  Explanatory  Key  to  the  Diagrams,  Price  .50 

Dr.  Marshall's  Plates,  from  their  size  and  perfection  of  drawing  and  coloring,  excel 
any  diagrams  that  have  been  published.  They  have  proved  invaluable  in  Medical 
Schools  and  Lecture  Rooms.  The  low  price  at  which  they  are  offered  brings  them 
within  reach  of  all. 

No.  I.  The  Skeleton  and  Ligaments.  No.  2.  The  Muscles,  Joints,  and  Animal  Mechanics.  No.  3.  The  Vis- 
cera in  Position— The  Structure  of  the  Lungs.  No.  4.  The  Organs  of  Circulation.  No.  5.  The  Lymphatics  or 
Absorbents.  No.  6.  The  Digestive  Organs.  No.  7.  The  Brain  and  Nerves.  No.  8.  The  Organs  of  the  Senses 
and  Organs  of  the  Voice,  Plate  i.  No.  9.  The  Organs  of  the  Senses,  Plate  2.  No.  10.  The  Microscopic 
Structure  of  the  Textures,  Plate  i.     No.  11.  The  Microscopic  Structure  of  the  Textures,  Plate  2. 

MARSDEN,  ON  CANCER. 

A  New  and  Successful  Mode  of  Treating  Certain  Forms  of  Cancer.  By  Alex- 
ander Marsden,  M.D.     Second  Edition.     Colored  Plates.     8vo.        Price  $3.00 

MARTIN,  MICROSCOPIC  MOUNTING. 

A  Manual  of  Microscopic  Mounting.  With  Notes  on  the  Collection  and  Ex- 
amination of  Objects,  and  upwards  of  150  Illustrations.  By  John  H.  Martin. 
Second  Edition,  Enlarged.     8vo.  Price  $2.75 

MORRIS,  ON  THE  JOINTS. 

The  Anatomy  of  the  Joints  of  Man.     Comprising  a  Description  of  the  Liga 
ments,  Cartilages,  and  Synovial  Membranes;  of  the  Articular  Parts  of  Bones, 
etc.     By  Henry  Morris,  f.r.c.s.     Illustrated  by  44  Large  Plates  and  Numerous 
Figures,  many  of  which  are  Colored.     8vo.  Price  $5.50 

MUTER,    MEDICAL   AND    PHARMACEUTICAL  CHEMIS- 
TRY. 

An  Introduction  to  Pharmaceutical  and  Medical  Chemistry.  Part  One. — 
Theoretical  and  Descriptive.  Part  Two. — Practical  and  Analytical.  Arranged 
on  the  principle  of  the  Course  of  Lectures  on  Chemistry  as  delivered  at,  and  the 
Instruction  given  in  the  Laboratories  of,  the  South  London  School  of  Pharmacy. 
By  John  Muter,  m.d..  President  of  the  Society  of  Public  Analysts.  A  Second 
Edition,  Enlarged  and  Rearranged.  The  Two  Parts  bound  in  one  large  octavo 
volume.  Price  $6.00 

Part  Two. — Practical  and  Analytical.  Bound  Separately,  for  the  Special  Con- 
venience of  Students.     Large  Svo.     Cloth.  Price  $2.50 

MAC  MUNN,  THE  SPECTROSCOPE. 

The  Spectroscope  in  Medicine.  By  Chas.  A.  Mac  Munn,  m.d.  With  3 
Chromo-lithographic  Plates  of  Physiological  and  Pathological  Spectra,  and  13 
Wood  Cuts.     Svo.  ■  Price  $3.00 

"  This  book  is,  without  question,  the  best  that  has  yet  been  published  on  the  subject ;  to  those  not  familiar  with 
Physiological  Spectroscopy  it  will  prove  interesting,  while  to  those  who  are  working  in  this  field  it  is  a  neces' 
Sity," — New  York  Medical  journal. 


28  p.  BLAKISTON,  SON  &-  CO:S 

MANN,  PSYCHOLOGICAL  MEDICINE. 

A  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
Diagnosis,  Pathology,  Prognosis  and  Treatment,  including  their  Medico-Legal 
Aspects ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d.,  of 
New  York.  With  Illustrations  of  Typical  Faces  of  the  Insane,  Handwriting  of 
the  Insane,  and  Micro-Photographic  Sections  of  the  Brain  and  Spinal  Cord, 
Octavo.      To  be  Ready  October  ist,  1883.  Cloth.  Full  Leather, 

MAUNDER,  OPERATIVE    SURGERY. 

Operative  Surgery.  Adapted  to  the  Living  and  Dead  Subject.  By  C.  F. 
Maunder,  f.r.c.s.  Second  Edition,  with  One  Hundred  and  Sixty-four  En- 
gravings on  Wood.  Price  $2.25 

BY   same   author. 

THE  ARTERIES. 

Surgery  of  the  Arteries,  including  Aneurisms,  Wounds,  Hemorrhages, 
Twenty-seven  Cases  of  Ligatures,  Antiseptic,  etc.  With  Illustrations.  Price  $1.50 

MAXON,  ON  PRACTICE. 

The  Practice  of  Medicine.     By  Edwin  R.  Maxon,  m.d,     8vo.       Price  $3.00 

MEADOWS,   OBSTETRICS,     Revised  Edition. 

A  Text-Book  of  Midwifery.  Including  the  Signs  and  Symptoms  of  Preg- 
nancy, Obstetric  Operations,  Diseases  of  the  Puerperal  State,  etc.  By  Alfred 
Meadows,  m.d.  Third  American,  from  Fourth  London  Edition.  Revised  and 
Enlarged.     With  145  Illustrations.     8vo.  Price  $2.00 


"  It  is  with  great  gratification  that  we  are  enabled 
to  class  Dr.  Meadows'  Manual  as  a  rare  exception, 
and  to  pronounce  it  an  accurate,  practical,  and  cred- 
itable work,  and  to  unhesitatingly  recommend  it  to 
both  student  and  practitioner." — American  yournal 
0/  Obstetrics. 

"  We  cannot  but  feel  that  everj'  teacher  of  Obstet- 
rics has  good  cause  to  congratulate  himself  on  being 
able  to  put  in  the  hands  of  the  student  a  book  which 
contains  so  much  valuable  and  reliable  information." 
— Philadelphia  Medical  Tit?tes. 


"  On  all  questions  of  treatment,  whether  by  medi- 
cines, by  hygienic  regimen,  or  by  mechanical  or  oper- 
ative appliances,  this  treatise  is  as  satisfactory  as  a 
work  of  manual  size  could  be  :  students  and  practi- 
tioners can  hardly  do  better  than  adopt  it  as  their 
vade  mecum." — The  Practitioner. 

"  The  systematic  arrangement  of  subjects,  and  the 
concise,  praetical  style  in  which  it  is  written,  make 
the  work  especially  valuable  as  a  student's  manual." 
Chicago  Medical  Examiner. 


MEARS,  PRACTICAL  SURGERY. 

Practical  Surgery.  Including  :  Part  i. — Surgical  Dressings  ;  Part  11. — Band- 
aging; Part  III. — Ligations;  Part  iv. — Amputations.  With  227  Illustrations. 
By  J.  Ewing  Mears,  m.d..  Demonstrator  of  Surgery  in  Jefferson  Medical  Col- 
lege, and  Professor  of  Anatomy  and  Clinical  Surgery  in  the  Pennsylvania  Col- 
lege of  Dental  Surger\'.     i2mo.  Price  $2.00 

"  Professor  Mears  has  written  a  convenient  and  use-  |  "  It  contains  a  great  deal  of  information  upon  the 
ful  book  for  students.  We  can  most  cordially  endorse  subjects  of  which  it  treats,  in  a  convenient  and  con- 
it  as  fulfilling  well  the  promise  made  in  its  modest  densed  form.  Each  division  is  well  illustrated,  thereby 
■pre.kx,^." -^Cincinnati  Lancet  and  Clinic.  j  rendering  the  text  doubly  clear. " — New  York  Medical 

I  Record. 

MILLER,  ON  ALCOHOL. 

Alcohol.    Its  Place  and  Power.    By  James  Miller,  f.r.c.s.  i2mo. 

MILLER  &  LIZARS,  ALCOHOL  AND  TOBACCO. 

Alcohol.  Its  Place  and  Power.  By  James  Miller,  f.r.c.s.  ;  and.  Tobacco, 
Its  Use  and  Abuse.  By  John  Lizars,  m.a.  The  two  essays  in  one  volume. 
i2mo.  Price  1 1. 00 


PUBLICATIONS. 


29 


MENDENHALL,  VADE  MECUM. 

The  Medical  Student's  Vade  Mecum.  A  Compend  of  Anatomy,  Physiology, 
Chemistry,  The  Practice  of  Medicine,  Surgery,  Obstetrics,  etc.  By  George 
Mendenhall,  m.d.     Eleventh  Edition.     224  Illustrations.     8vo.         Price  ^2.00 

MEIGS  AND  PEPPER,  DISEASES  OF  CHILDREN. 

A  Practical  Treatise  on  the  Diseases  of  Children.  By  J.  Forsyth  Meigs,  m.d.. 
Fellow  of  the  College  of  Physicians  of  Philadelphia,  etc.,  etc.,  and  William 
Pepper,  m.d.,  Physician  to  the  Philadelphia  Hospital,  Provost  University  of 
Pennsylvania.  Seventh  Edition,  thoroughly  Revised  and  Enlarged.  A  Royal 
Octavo  Volume  of  over  1000  pages.  Price,  Cloth,  0.oo;  Leather,  ^7.00 

"  With  the  recent  additions  it  may  safely  be  pronounced  one  of  the  best  and  most  compiehensive  works  on  Dis- 
eases of  Children." — New  York  Medical  jfoumal. 

"  Must  be  regarded  as  the  most  complete  work  on  Diseases  of  Children  in  our  language." — Edinburgh  Medical 
Journal. 

"  We  have  seldom  met  with  a  text-book  so  complete,  so  just  and  so  readable  as  the  one  before  us." — American 
Journal  of  Obstetrics. 

MATHIAS,  LEGISLATIVE  MANUAL. 

A  Rule  for  Conducting  Business  in  Meetings  of  Societies,  Legislative  Bodies, 
Town  and  Ward  Meetings,  etc.  By  Benj.  Mathias,  a.m.  Sixteenth  Editiorx. 
i6mo.  Price  .50 

MORTON,  REFRACTION  OF  EYE. 

The  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy.     By  A.  Stanford  Morton,  m.b.,  f.r.c.s.     i2mo. 

Price  ;^i.oo 

"  The  author  has  not  only  given  very  thorough  rules  for  the  objective  and  subjective  examinations  of  the  eye  in 
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ena observed,  which  is  at  once  scientific  and  elementary." — Edinbtirgh  Medical  Journal. 

OVERMAN,  MINERALOGY. 

Practical  Mineralogy,  Assaying,  and  Mining,  with  a  Description  of  the  Useful 
Minerals,  etc.  By  Frederick  Overman,  Mining  Engineer.  nth  Edition. 
l2mo.     Cloth.  Price  $1.00 

OGSTON,  MEDICAL  JURISPRUDENCE. 

Lectures  on  Medical  Jurisprudence.  By  Drs.  Francis  and  Francis  Ogston, 
Jr.     With  Copper-plate  Illustrations.     8vo.  Price  ^6.00 

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ing all  that  the  distinguished  author  promised  for  it." — Atnerican  Journal  of  Medical  Science. 

OLDBERG,  PRESCRIPTION  BOOK.     300  New  Prescriptions. 

Three  Hundred  Prescriptions,  Selected  Chiefly  from  the  Best  Collections  of 
Formulae  used  in  Hospital  and  Out-patient-practice,  with  a  Dose  Table,  and  a 
Complete  Account  of  the  Metric  System.  By  Oscar  Oldberg,  phar.  d..  Late 
Medical  Purveyor,  United  States  Marine  Hospital  Service ;  Professor  of  Materia 
Medica,  National  College  of  Pharmacy,  Washington,  D.  C. ;  Member  of  the 
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formularies  of  the  great  Hospitals  of  New  York,  Philadelphia,  Boston  and  London, 
or  contributed  from  the  practice  of  medical  officers  of  the  United  States  Service.  The 
Dose  Table  includes  nearly  all  of  the  remedies  that  have  a  place  in  the  current 

Materia  Medica. 


30  P.  BLAKISTON,  SON  &-  CO.'S 

BY   SAME   AUTHOR. 

THE  UNOFFICIAL  PHARMACCPCEIA. 

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Wholesale  Druggists,  New  York  City. 

OTT,  ACTION  OF  MEDICINES. 

The  Action  of  Medicines.  By  Isaac  Ott,  m.d.,  late  Demonstrator  of  Experi- 
mental Physiology  in  the  University  of  Pennsylvania.  With  22  Illustrations. 
8vo.  Price  $2.00 

PAGE,  INJURIES  OF  THE  SPINE. 

Injuries  of  the  Spine  and  Spinal  Cord,  without  apparent  Lesion  and  Nervous 
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PAGET,  SURGICAL  PATHOLOGY. 

Lectures  on  Surgical  Pathology,  Delivered  at  the  Royal  College  of  Surgeons. 
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PARKES,  PRACTICAL  HYGIENE.     Sixth  Edition. 

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PIESSE,  THE  MANUFACTURE  OF  PERFUMERY.    Fourth 
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PROCTER'S  PRACTICAL  PHARMACY. 

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Cloth,  $4.50. 

PARRISH,  ALCOHOLIC  INEBRIETY. 

Alcoholic  Inebriety  from  a  Medical  Standpoint,  with  Illustrative  Cases  from 
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PUB  Lie  A  TIONS.  31 


POTTER'S     COMPENDS,    FOR    PHYSICIANS    AND    "STU- 
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tion Room.     By  Samuel  O.  L.  Potter,  m.d. 
ANATOMY,  with  63  Illustrations. 
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macopoeia.    i2rao.     Cloth. 

Price  for  each.  Interleaved  for  taking  Notes,  ^1.25  ;  plain,  $1.00 
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SPEECH,  AND  ITS  DEFECTS. 

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the  Lea  Prize  Thesis  of  Jefferson  Medical  College,  1882.  Revised  and  Corrected 
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PENNSYLVANIA  HOSPITAL  REPORTS. 

Edited  by  a  Committee  of  the  Hospital  Staff.  J.  M.  DaCosta,  m.d.,  and 
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and  present  Members  of  the  Staff.  With  Lithographic  and  other  Illustrations. 
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PEREIRA,  PRESCRIPTION  BOOK.     Sixteenth  Edition. 

Physician's    Prescription    Book.     Containing   Lists  of  Terms,   Phrases,  Con- 
tractions and  Abbreviations  used  in  Prescriptions,  Explanatory  Notes,  Gram- 
matical Construction  of  Prescriptions,  Rules  for  the  Pronunciation  of  Pharma- 
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This  last  is  a  most  valuable  addition,  and  will  materially  aid  the  Physician.  So 
many  writers  now  use  the  metric  system,  especially  in  foreign  books  and  journals, 
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32  P.BLAKISTON,  SON  &-  CO:S 

POWER,  HOLMES,  ANSTIE  AND  BARNES  {Drs.). 

Reports  on  the  Progress  of  Medicine,  Surgery,  Piiysiology,  Midwifer}-,  Dis- 
eases of  Women  and  Children,  Materia  IMedica,  Medical  Jurisprudence,  Ophthal- 
mology', etc.,  etc.     Reported  for  the  New  Sydenham  Society.     8vo.     Price  §2.00 

PURCELL,  ON  CANCER. 

Cancer.  Its  Allies  and  other  Tumors,  with  Specia  Reference  to  their  Medi- 
cal and  Surgical  Treatment.  By  F.  Albert  Purcell,  m.d  ,  m.r.c.S.  Surgeon 
to  the  Cancer  Hospital,  Brompton,  England.     8vo.  Price  $3.75 

RADCLIFFE,  ON  EPILEPSY. 

On  Epilepsy,  Pain,  Paralysis,  and  other  Disorders  of  the  Nervous  System. 
By  Charles  Bland  R,\dcliffe,  m.d.     Illustrated.     i2mo.  Price  $1.50 

"  To  no  authoritj'  can  the  medical  inquirer  turn  for  an  analysis  of  the  phenomena  of  epilepsy  with  more  satisfac- 
tion than  to  the  admirable  essay  of  Dr.  Radcliffe." — Atnerican  yournal  Medical  Sciences. 

ROBERTS,  MANUAL  OF  MIDWIFERY. 

The  Student's  Guide  to  the  Practice  of  Midwifery.  By  D.  Lloyd  PvOBERTs, 
M.D.,  F.R.C.P.,  Physician  to  St.  Alary's  Hospital,  ]Man Chester,  etc.,  etc.  Second 
Edition.     With  95  Illustrations.     i2mo.  Price  §1.25 

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erts  one  of  the  best  now  offered  to  the  Profession,  as  it  vised,  some  chapters  having  been  entirely  re -written, 

comes  with  authority,  and  he  possesses  the  ability  to  For  its  size,  it  forms  a  remarkably  complete  compendi. 

condense,  and  at  the  same  time  present  a  subject  clear-  um  of  the  subject,  and  can  hardly  be  surpassed  in  the 

Ij'." — Atnerican  yournal  of  Medical  Science.  '     simplicity  and  clearness  of  its  explanations." — Obstet- 

"  Concise,   clear,   and    practical." — Medical  Press  rical  yournal  of  Great  Britain  and  Ireland, 

and  Circular.  | 

REYNOLDS,   ELECTRICITY, 

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tioner."—  Canada  Lancet. 

RICHARDSON,    MECHANICAL    DENTISTRY.      Third   Edi- 
tion. 

A  Practical  Treatise  on  Mechanical  Dentistry.  By  Joseph  Richardson,  d.d.s. 
Third  Edition.     With  185  Illustrations.    8vo.    Price,  Cloth,  $4.00 ;  Leather,  $4.75 

"  Taken  as  a  whole.  Professor  Richardson's  work  is  a  valuable  contribution  to  the  dental  art,  and  is  beyond  all 
question  the  best  treatise  extant  upon  the  general  subject  of  Mechanical  Dentistry." — Dental  Cosmos. 

RIGBY  AND  MEADOWS,  OBSTETRIC  MEMORANDA. 

Dr.  Rigby's  Obstetric  :\Iemoranda.  Fourth  Edition.  Revised.  By  Alfred 
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PIGGOTT,  ON  COPPER. 

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PRINCE,  ORTHOPEDIC  SURGERY. 

Plastic  and  Orthopedic  Surger}-.  By  David  Prince,  m.d.  Contaming  a 
Report  on  the  Condition  of,  and  Advance  made  in,  Plastic  and  Orthopedic  ^Sur- 
gery, etc.,  etc.,  and  Numerous  Illustrations.     8vo.  Price  $4.50 

RYAN,  ON  MARRIAGE.  ^     .,.„,.' 

The  Philosophv  of  INIarriage.  In  its  Social,  Moral  and  Physical  Relations 
and  Diseases  of' the  Urinary-  Organs.  By  Michael  Ryan,  m.d.  Member  of 
the  Royal  College  of  Physicians,  London.     i2mo.  Price  $1.00 


PUB  Lie  A  TIONS.  33 


ROBERTS,  PRACTICE  OF  MEDICINE.     Fourth  Edition. 

The  Theory  and  Practice  of  Medicine.  By  Frederick  Roberts,  m.d. 
Third  American,  from  the  Fourth  London  Edition.     8vo. 

Price,  Cloth,  I5.00  ;  Leather,  $6.00 

Recommended  at  the  University  of  Pennsylvania,  Yale  and  Dartmouth  Colleges, 
University  of  Michigan,  and  many  other  Medical  Schools. 

The  unexceptional  large  and  rapid  sale  of  this  book,  and  the  universal  commen- 
dation it  has  received  frorrt  the  profession,  seems  to  be  a  sufficient  guarantee  of  its 
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Professors  in  the  medical  schools,  speaking  favorably  of  it,  and  below  they  g-ive 
extracts  from  the  medical  press,  American  and  English,  attesting  its  superiority  and 
value  to  both  student  and  practitioner.  The  present  edition  has  been  thoroughly 
revised  and  much  of  it  re-written. 

"The  best  Text-book  for  Students  hi  the  English  |  "To  the  student  it  will  be  a  gift  of  priceless  value." 
language.     We  know  of  no  work  in  the  English  Ian-    ■ — Detroit  Revieiu  of  Medicine. 

guage,   or  in   any   other,   which  competes  with   this  1      «  Wg  heartily  recommend  it  to  students,  teachers, 
one.'  —Edinburgh  Medical  Journal.^  I  3^^   practitioners."— ^orf^«   Medical  and    Surgical 

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ence,  and  research."— Practitioner.  <<  jj  i^  of  ^  much  higher  order  than  the  usual  compi- 

"  Dr.   Roberts'  book  is  admirably  fitted  to  supply      ations  and  abstracts  placed  in  the  hands  of  students." 
the  want  of  a  good  hand-book,  so  much  felt  by  every     1 — Medical  and  Surgical  Reporter. 
medical  iX^xAexit."— Student's  Journal  and  Hospital        .<  j^  jg  unsurpassed  by  any  work  that  has  fallen  into 
Gazette.  lour    hands    as   a   compendium    for    students."  —  The 

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"  There  are  great  excellencies  in  this  book,  which     enter  upon  the  practice  of  their  profession." — St.  Louis 
will  make  it  agreat  favorite  with  the  student." — Rich-     Medical  and  Surgical  jfournal. 
vwnd  and  Louisville  fournal.  \ 

RINDFLEISCH,  GENERAL  PATHOLOGY. 

General  Pathology;  a  Handbook  for  Students  and  Physicians.  By  Prof. 
Edward  Rindfleisch,  of  Wurzburg.  Translated  by  Wm.  H.  Mercur,  m.d., 
Edited  and  Revised  by  James  Tyson,  m.d.,  Professor  of  Morbid  Anatomy  and 
Pathology,  University  of  Pennsylvania.     Octavo.  Cloth, 

In  Rapid  Preparation . 

RINDFLEISCH,  PATHOLOGICAL  HISTOLOGY. 

A  Text-Book  of  Pathological  Histology.     By  Dr.   Edward  Rindfleisch.' 
Translated  by  Drs.  Wm.  C.  Kolman  and   F.  T.  Miller.     208  Illustrations. 
Svo. 
Recommended  as  a  Text-Book  at  the  University  of  Pennsylvania  and  other  Med- 
ical Schools. 

"  To  be  up  with  the  times,  our  Pathologists  must  make  themselves  familiar  with  the  thorough,  clear,  and  al- 
most exhaustive  teachings  of  Professor  Rindfleisch." — Ohio  Medical  and  Surgical  Reporter. 

ROYLE  AND  HARLEY,  MATERIA  MEDICA.     Sixth  Edition. 

A  Manual  of  Materia  Medica  and  Therapeutics.  By  Dr.  J.  Forbes  Royle. 
Sixth  Edition.  Edited  by  John  Harley,  m.d.  840  pages  and  numerous  Illus- 
trations.    Demi  Svo.  '  Price  |;5.oo 

RUTHERFORD,  PRACTICAL  HISTOLOGY. 

Outlines  of  Practical  Histology  ;  being  the  Notes  of  the  Course  of  Practical 
Physiology  given  in  King's  College,  London,  and  the  University  of  Edinburgh. 
By  William  Rutherford,  m.d.,  f.r.s.,  Professor  of  the  Institutes  of  Medicine 
in  the  University  of  Edinburgh  (with  additional  leaves  for  Notes).  Third  Edi- 
tion.    Illustrated.  \^In  Press. 

"  To  the  student  and  teacher  of  Practical  Histology,  this  work  can  hardly  help  being  a  great  boon.  It  is 
complete,  yet  short,  perfectly  clear  and  simple,  and  moreover  every  line  bespeaks  the  outcome  of  an  extensive 
practical  acquaintance  with  the  subject." — Medical  Times  and  Gazette,  London. 


34  P-  BLAKISTON,  SON  &-  CO.'S 

SANDERSON  AND  FOSTER,  THE    PHYSIOLOGICAL  LA- 
BORATORY. 

A  Hand-book  of  the  Physiological  Laboratory.  Being  Practical  Exercises  for 
Students  in  Physiology  and  Histology.  By  J.  Burdon  Sanderson,  m.d.,  E. 
Klein,  m.d.,  Michael  Foster,  m.d.,  f.r.s.,  and  T.  Lauder  Brunton,  m.d. 
With  over  350  Illustrations  and  Appropriate  Letter-press  Explanations  and  Ref- 
erences. 

Price.  Two  Volumes,  Text  and  Plates,  separate,       -         .         -    ^6.00 

"      One  "  "  "  bound  together.  Cloth,        5.00 

"         "  "  "  "  "  "  Leather,    6.00 

Adopted  as  a  Text-book  at  Yale  College,  and  used  at  other  Medical  Schools  in 

America  and  England. 

"  Recognizing  the  fact  that  Physiology  is  emphatic- 
ally an  experimental  science,  it  furnishes  minute  in- 
structions for  performing  a  great  variety  of  exper- 
iments. A  student  could  scarcely  desire  a  better  guide." 
— Boston  Medical  and  Surgical  Journal. 


"  We  confidently  recommend  it  to  the  attention  of  all 
who  are  interested  in  the  wide  and  fertile  field  of  Phy- 
siological research." — New  York  Medical  Journal. 

"  This  is  a  most  superb  bonk,  and  fills  a  hiatus  which 
every  physiological  student  has  lamented." — Chicago 
Medical  Journal. 


SANDERSON,  PHYSIOLOGY.     Second  Edition. 

A  Syllabus  of  a  Course  of  Lectures  on  Physiology.  By  J.  Burdon  Sander- 
son, m.d.     For  the  Use  of  Students.     Second  Edition.     8vo.  Price  $1.50 

SANDERSON,  PRACTICAL  EXERCISES  IN  PHYSIOLOGY. 

8vo.     Illustrated.  Price  $1.12 

SANSOM,  PHYSICAL  DIAGNOSIS.     Third  Edition  just  ready. 

The  Physical  Diagnosis  of  Diseases  of  the  Heart.  Including  the  Use  of  the 
Sphygmograph  and  Cardiograph.  By  Arthur  Ernest  Sansom,  m.d.  Third 
Edition.     Revised  and  Enlarged.     With  Illustrations.     i2mo.  Price  $2.00 

BY  same   author. 

DISEASES  OF  THE  HEART. 

The  Lettsomian  Lectures  on  the  Treatment  of  some  of  the  Forms  of  Valvular 
Disease  of  the  Heart.     Illustrated.     i2mo.  Cloth,  $1.25 

BY   same   author. 

ON    CHLOROFORM. 

Chloroform.     Its  Action  and  Administration.     i2mo.  Price  $1.50 

SMITH,  MANUAL  OF  GYNAECOLOGY. 

Practical  Gynaecology.  A  Hand-book  of  the  Diseases  of  Women.  By  Hey- 
WOOD  Smith,  m.d.  Physician  to  the  Hospital  for  Women  and  to  the  British 
Lying-in  Hospital.     With  Engravings.  Price  $1.25 

The  object  of  the  author  has  been  to  present  the  busy  practitioner  with  a  book 
systematically  arranged,  burdened  with  no  discussions  on  vexed  questions  of  pathol- 
ogy, and  giving  at  a  glance  the  salient  points  of  diagnosis  and  treatment  with  clear- 
ness and  brevity, 

by  same  author. 

DYSMENORRHCEA.    Just  Issued. 

Its  Pathology  and  Treatment.     i2mo.  Price  $1-75 

SMITH,  RINGWORM. 

The  Diagnosis  and  Treatment  of  Ringworm.  By  Alder  Smith,  f.r.c.s. 
With  Illustrations.     i2mo.        •  Price  $1.00 

SMITH,  ON  NURSING. 

The  Efficient  Training  of  Nurses  for  Hospital  and  Private  Practice.     By  WiL-      I 
liam  Robert  Smith.     Illustrated.     Third  Edition.  Price  ' 


PUB  Lie  A  TIONS. 


3'5 


SMITH,  ON  CHILDREN. 

Clinical  Studies  of  Diseases  in  Children. 
Revised  Edition. 


By  Eustace  Smith,  m.d.   Second 
Price  $2.50 

MEDICAL  HERESIES,  HISTORICALLY  CONSIDERED. 

A  Series  of  Critical  Essays  on  the  Origin  and  Evolution  of  Sectarian  Medi- 
cine, embracing  a  Special  Sketch  and  Review  of  Homoeopathy,  Past  and  Pres- 
ent. By  GoNZALVO  C.  Smythe,  a.m.,  m.d.  Professor  of  the  Principles  and 
Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  Indianapolis,  Indi- 
ana.    i2mo.     Cloth.  Price  ^1.25 

"  Students  and  others  interested  in  the  subject  of 
medicine  will  find  a  digest  of  the  entire  controversy 
(between  the  various  schools  of  niedi'=-.ine)  presented  in 
this  volume." — Journal  of  Educati.jn. 

"  Professor  Smythe  has  succeeded  in  writing  a  brief, 
clear,  and  interesting  sketch  of  the  evolution  of  medical 
eccentricities,  and  of  modern  homoeopathy,  its  facts  and 
fallacies." — Philadelphia,  Medical,  Titnes. 


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history  of  medicine,  from  its  earliest  day  to  the  present 
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"Cannot  fail  to  be  of  interest,  not  only  to  the  medi- 
cal profession,  but  io  the  general  reader." — Baltimore 
Gazette. 

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SAVAGE,  FEMALE  PELVIC  ORGANS.     Author's  Edition. 

The  Surgery,  Surgical  Pathology  and  Surgical  Anatomy  of  the  Female  Pelvic 
Organs.  In  a  Series  of  Colored  Plates  taken  from  Nature,  with  Commentaries, 
Notes  and  Cases.  By  Henry  Savage,  m.d.,  f.r.c.s.  New  Edition.  Issued  by 
arrangement  with  the  Author,  from  the  original  Plates.     Quarto.       Price  $12.00 

SAVORY  &  MOORE,  DOMESTIC  MEDICINE. 

A  Condensed  Compend  of  Domestic  Medicine,  and  Companion  to  the  Medi- 
cine Chest.     By  Drs.  Savory  and  Moore.     Illustrated.     i6mo.  Price  .50 

SCHULTZE,  OBSTETRICAL  PLATES. 

Obstetrical  Diagrams.  Life  Size.  By  Prof.  B.  S.  Schultze,  m.d.,  of  Berlin. 
Twenty  in  the  Set.     Colored. 

Price,  in  Sheets,  $15.00 ;  Mounted  on  Rollers  $25.00 

SCANZONI,  DISEASES  OF  WOMEN. 

A  Practical  Treatise  on  the  Diseases  of  the  Sexual  Organs  of  Women.  By 
Dr.  F.  W.  Von  Scanzoni.     Translated  by  A.  K.  Gardiner,  m.d.     8vo. 

Price  $5.00 
SIEVEKING,  LIFE  ASSURANCE. 

The  Medical  Adviser  in  Life  Assurance.  By  E.  H.  Sieveking,  m.d.  i2mo. 
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SHEPPARD,  ON  MADNESS. 

Madness,  in  its  Medical,  Social  and  Legal  Aspects.  A  series  of  Lectures  de- 
livered at  King's  Medical  College,  London.     By  Edgar  Sheppard,  m.d.     8vo. 

Price  $2.25 

STOCKEN,  DENTAL  MATERIA  MEDICA.     Third  Edition. 

The  Elements  of  Dental  Materia  Medica  and  Therapeutics  with  Pharmacopoeia. 
By  James  Stocken,  d.d.s.     Third  Edition.     i2mo.  $2.50 

The  first  edition  of  this  book  was  disposed  of  in  a  little  less  than  four  months.  In 
making  this  revision  the  author  has  endeavored  to  make  it  still  more  useful  by  the 
addition  of  considerable  new  matter. 

SUTTON,  VOLUMETRIC  ANALYSIS.     Fourth  Edition. 

A  Systematic  Handbook  of  Volumetric  Analysis,  or  the  Quantitative  Estima- 
tion of  Chemical  Substances  by  Measure,  Applied  to  Liquids,  Sohds,  and  Gases. 
By  Francis  Sutton,  f.c.s.  Fourth  Edition.  Revised  and  Enlarged,  with  Illus- 
trations.    8vo.  Price  $5.00 


36  P.  BLAKISTON,  SON  S^  CO.'S 

SEWELL,  DENTAL  ANATOMY  AND  SURGERY. 

A  Manual  of  Dental  Anatomy  and  Surgery,  Including  the  Extraction  of  Teeth. 
By  H.  E.  Sewell,  d.d.s.,  m.d.     With  yj  Illustrations.     i2mo.  Price  $1.25 

"  A  valuable  book  for  the  general  Practitioner  who  "  It  will  be  found  useful  to  the  general  Practitioner  in 

te  in  want  of  a  practical  manual  relating  especially  to    |  themanagement  of  many  incidental  affections  connected 

diseases  of  the  teeth." — Medical  Brit-f.                              •  with  the   teeth   and  mouth,  which   cannot  always  be 

)  handed  over  to  the  speciahst." — Pacific  Med.  yournal. 

STILLE,  ON  MENINGITIS. 

Epidemic  Meningitis,  or  Cerebro-spinal  Meningitis.  By  Alfred  Stille,  m.d., 
Professor  of  Practice  at  the  University  of  Pennsylvania.     8vo.  Price  $2.00 

"  The  name  of  the  author  is  a  sufficient  guarantee  that  this  monograph  is  elegant  in  style,  exhaustive  of  its  sub- 
ject and  rich  with  practical  suggestions.'' — Philadelphia  Medical  and  Surgical  Reporter. 

STOKES,  DISEASES  OF  THE  HEART. 

The  Diseases  of  the  Heart  and  Aorta.  By  William  Stokes,  m.d.  Thick 
8vo.  Price  I3.00 

SWAIN,  SURGICAL  EMERGENCIES. 

Surgical  Emergencies:  Concise  Descriptions  of  the  Various  Accidents  and 
Emergencies,  with  Directions  for  their  Treatment.  By  Wm.  Paul  Swain,  f.r. 
C.s.     Eighty-two  Illustrations.     l2mo.  Price  $2.00 

Contents. — Chapter  I.  Injuries  to  the  Head.  II.  Injuries  to  the  Eye.  III.  Injuries  to  the  Mouth, 
Pharynx,  CEsophagus,  and  Larynx.  IV.  The  Chest.  V.  The  Upper  Extremity.  VI.  The  Abdomen.  VII. 
The  Pelvis.  VIII.  The  Lower  Extremitj'.  IX.  Emergencies  connected  with  Parturition.  X.  Poisoning. 
XI.  Antiseptic  Treatment.     XII.  Apparatus  and  Dressing. 

"  Many  surgeons  will  thank  Dr.  Swain  for  the  trouble  he  has  taken  to  put  them  easily  in  possession  of  this  re- 
ftesher  of /z«^  forgotten  knowledge. —  The   Practitioner. 

SWERINGEN,  REFERENCE  BOOK. 

A  Pharmaceutical  Lexicon  or  Dictionary'  of  Pharmaceutical  Science.    Contain- 
*      ing  explanations  of  the  various  subjects  and  terms  of  Pharmacy,  with  appropriate 
selections  from  the  Collateral  Sciences.     Formula  for  Officinal,  Empirical,  and 
Dietetic  Preparations,  etc.,  etc.     By  Hiram.  V.  Sweringen,  m.d.     8vo. 

Price,  Cloth,  $3.00 ;  Leather,  $4.00 

"  It  is  worthy  of  a  welcome,  and  sure  of  a  ready  recognition  of  its  merits." — LoTidon  Pkarmaceiitical  journal. 
"  It  will  prove  of  great  service  to  the  pharmaceutical  student,  apprentice,  pharmacist,  druggist  and  physician,  as 
a  book  of  ready  reference  and  as  an  aid  to  the  study  of  scientific  works." — American  Journal  of  Pliarmacy. 

THOMPSON,  LITHOTOMY  AND  LITHOTRITY. 

Practical  Lithotomy  and  Lithotrity ;  or,  an  Inquiry  into  the  best  Modes  of 
Removing  Stone  from  the  Bladder.  By  Sir  Henry  Thompson,  f.r.c.s..  Emer- 
itus Professor  of  Clinical  Surgery  in  University  College.  Third  Edition.  8vo. 
With  87  Engravings.  Price  $3.50 

"  The  chapters  of  most  interest  are  those  in  which  Bigelow's  operation  is  discussed,  and  the  final  one,  in 
v/hich  is  a  record  of  500  operations  for  stone  in  cases  of  male  adults  under  the  author's  care.  Such  a  table  has 
never  before  been  compiled  by  any  surgeon." — Laficet. 

BY   SAME   AUTHOR. 

URINARY  ORGANS.     Seventh  Edition. 

Diseases  of  the  L^rinary  Organs.  Clinical  Lectures.  Seventh  London  Edition. 
Enlarged,  with  73  Illustrations.  Price,  Cloth,  11.25  I  Paper,  .75 

ON  THE  PROSTATE. 

Diseases  of  the  Prostate.  Their  Pathology  and  Treatment.  Fifth  London 
Edition.     Svo.     With  Numerous  Plates.     Price,  Cloth,  gi. 25  ;  Paper,  .75. 

CALCULOUS  DISEASES. 

The  Preventive  Treatment  of  Calculous  Disease,  and  the  Use  of  Solvent 
Remedies.     Second  Edition.     i6mo.  Price  $\.oo 

"  Catholic  in  his  investigation  of  the  fruit  of  the  labor  of  others,  cautious  in  all  his  deductions,  rejecting  all  spe- 
cious theories  in  the  effort  to  obtain  practically  useful  results,  as  clever  with  his  pen  as  he  is  with  the  sound  or 
lithotrite,  one  can  scarcely  wonder  that  he  is  esteemed  the  master  that  he  is." — American  Journal  af  Medical 
Science. 


PUBLICA  TIONS.  37 


THOMPSON,  COUGHS  AND  COLDS. 

The  Causes,  Nature,  and  Treatment  of  Coughs  and  Colds.  By  E.  S.  Thomp- 
son, M.D.     i6mo.  Price  .60 

THOROWGOOD,  MATERIA  MEDICA. 

The  Student's  Guide  to  Materia  Medica.  By  John  C.  Thorowgood,  m.d. 
Illustrated.     318  pages.     i2mo.  Price  ^2.00 

BY   SAME  AUTHOR. 

ON  ASTHMA. 

The  Forms,  Nature,  and  Treatment  of  Asthma.     i2mo. 

TUSON,  VETERINARY  PHARMACOPCEIA. 

A  Pharmacopoeia,  Including  the  Outlines  of  Materia  Medica  and  Therapeu- 
tics. For  the  Use  of  Students  and  Practitioners  of  Veterinary  Medicine.  By 
Richard  V.  Tuson,  f.c.s.     Third  Edition.     i2mo.  Price  $2.50 

"  Not  only  practitioners  and  students  of  veterinary  medicine,  but  chemists  and  druggists  will  find  that  this 
book  supplies  a  want  in  veterinary  literature." — Druggist  and  Chemist. 

THUDICHUM  ON  THE  URINE.     Second  Edition. 

The  Pathology  of  the  Urine  and  Complete  Guide  to  Analysis.  By  John  L. 
W.    Thudichum,    m.d.      Second    Edition.     Enlarged  and    Illustrated.      8vo. 

Price  $5.00 

"The  treatise  of  Dr.  Thudichum  is  well  known  as  one  of  the  medical  classics  of  the  language,  and  in  com- 
pleteness, thoroughness,  and  originality,  the  volume  before  us  has  few  rivals  in  any  branch  of  our  science.  For 
the  specialist,  for  the  physiological  chemist,  for  the  physiologist,  the  volume  of  Dr.  Thudichum  is  a  sine  qua 
lion,  and  to  such  the  new  edition  must  be  a  most  welcome  guest." — Philadelphia  Medical  Times. 

TROUSSEAU,  CLINICAL  MEDICINE. 

Lectures  on  Clinical  Medicine,  Delivered  at  the  Hotel  Dieu,  Paris,  by  A. 
Trousseau,  Professor  of  Clinical  Medicine  to  the  Faculty  of  Medicine,  Paris, 
etc.,  etc.  Translated  from  the  Third  Revised  and  Enlarged  Edition  by  P.  Vic- 
tor Bazire,  m.d  ,  London  and  Paris  ;  and  John  Rose  Cormack,  m.d.,  Edin- 
burgh, F.R.S.,  etc.  With  a  full  Index,  Table  of  Contents,  etc.  2  vols.  8vo. 
Sold  by  Subscription  only.  Price,  Cloth,  ^8.00;  Leather,  ^10.00 

Sydenham  Edition,  Same  Work.  5  Vols.  8vo.  Large  Print.  Price  $15.00 
Trousseau's  Lectures  have  attained  a  reputation,  both  in  England  and  in  this 
country,  far  greater  than  any  work  of  a  similar  character  heretofore  written.  In 
order  to  bring  the  work  within  the  reach  of  all  the  profession,  the  publishers  now 
issue  an  American  edition,  containing  all  the  lectures  as  contained  in  the  five-vol- 
ume Sydenham  edition,  at  a  much  lower  price.  Below  are  a  few  only  of  the  many 
favorable  opinions  expressed  of  the  work : — 


"  a  clever  translation  of  Prof.  Trousseau's  admirable 
and  exhaustive  work  ;  the  best  book  of  reference  upon 
the  Practice  of  Medicine." — hidiana  Medical  Gazette. 


TEST  TYPES. 


"  We  scarcely  know  of  any  book  better  fitted  for 
presentation  to  a  young  man  when  entering;  upon  the 
practical  work  of  his  life." — Londoti  Medical  Times 
and  Gazette. 


Selections  from  Snellen's  Test  Types  mounted  upon  heavy  card  board ;  suit- 
able for  hanging  in  the  office.  •  Price  50  cents 

TIDY,  MODERN  CHEMISTRY. 

A  Hand-Book  of  Modern  Chemistry.     Organic  and  Inorganic.     By  C.  Mey- 
MOTT  Tidy,  m.d.     8vo.  Price  $5.00 

"We  doubt  if  any  other  chemical  work  containing  so  large  an  amount  of  information  could  be  procured." — 
Ihiblin  Medical  journal. 


p.  BLAKISTON,  SON  <&-  CO:S 


TILT,  THE  CHANGE  OF  LIFE  IN  WOMEN. 

The  Change  of  Life  in  Health  and  Disease.  A  Practical  Treatise  on  the 
Diseases  incidental  to  Women  at  the  Decline  of  Life.  By  Edward  John  Tilt, 
M.D.     Fourth  London  Edition.     8vo.  Price,  Cloth,  $1.25;  Paper  cover,  .75 

"  We  believe  Dr.  Tilt  brings  much  more  than  ordinary  merit  to  bear  on  his  subject,  and  handles  it  accord- 
ingly.    Few  books  are  issued  that  are  more  indispensable  to  the  general  practitioner." — Phila.  Med.  Times. 

"  Dr.  Tilt's  clear  and  concise  style  makes  the  book  at  once  a  pleasant  one  to  read  and  an  ea.sy  guide  to  follow, 
and  we  are  quite  sure  it  is  the  most  valuable  one  we  have  on  the  subject." — Boston  Med.  &"  Surg,  jfoumal. 

"  The  best  work  on  the  subject." — London  Lancet. 

TOMES,  DENTAL  ANATOMY.     Second  Edition. 

A  Manual  of  Dental  Anatomy,  Human  and  Comparative.  By  C.  S.  Tomes, 
D.D.s.     With  179  Illustrations.     Second  Edition.     i2mo.  Price  ^.25 

TOMES,  DENTAL  SURGERY. 

A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s.  The  Second  Edition, 
Revised  and  Enlarged.     By  C.  S.  Tomes,  d.d.s.     With  263  Illustrations.     i2mo. 

Price  J5.00 

"  We  rejoice  that  such  books  as  these  (Dr.  Tomes'  Works)  are  demanded  by  the  profession,  and  that  the  men 
to  write  them  are  furnished  by  the  profession." — Dental  Cos}kos. 

TAFT,  OPERATIVE  DENTISTRY.     Fourth  Edition. 

A  Practical  Treatise  on  Operative  Dentistry.  By  Jonathan  Taft,  d.d.s. 
Fourth  Revised  and  Enlarged  Edition.     Over  100  Illustrations.     8vo. 

Price,  Cloth,  $4.25  ;  Leather,  5.00 

"All  the  important  operations,  in  all  their  modifica-  i        "  It  is  a  thorough  and  complete  treatise  on  the  Art 

f;ons,  are   clearly  discussed   by  the   author,   and    the  '    of  Practical  Dentistry." — London  Medical  Times  and 
work  is  highly  practical  throughout." — Dental  Regis-        Gazette. 
ter. 

TANNER,  INDEX  OF  DISEASES.     Second  Edition. 

An  Index  of  Diseases  and  their  Treatment.    By  Thos.  Hawkes  Tanner,  m.d., 

F.R.C.P.    Second  Edition.    Revised  and  Enlarged.    By  W.  H.  Broadbent,  m.d. 

With  Additions.     Appendix  of  Formulae,  etc.     8vo.  Price  $3.00 

By  this  useful  hand-book  the  character  of  any  disease  may  be  determined  in  a 

moment,  and  the  general  outline  of  treatment  pursued  by  the  best  authorities  made 

apparent. 

"  This  work,  like  others  from  the  gifted  author,  has  j  "  Finally,  a  chapter  on  the  climates,  countries,  mine- 
already  won  for  itself  a  reputation."  .  .  .  "  It  is  ral  springs,  etc.,  best  adapted  to  the  various  classes  of 
in  truth  what  its  title  indicates." — New  York  Medical  invalids,  makes  this  work  the  most  complete  practi- 
Record.  tioner's  manual  that  we  have  yet  seen. — Chicago  Medi- 

\  cal  Tiines. 

BY   SAME  AUTHOR. 

THE  DISEASES  OF  INFANCY. 

A  Practical  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  Third  Edi- 
tion. Carefully  Revised  and  much  Enlarged.  By  Alfred  Meadows,  m.d. 
8vo.  Price  $3.00 

Recommended  as  a  Text-book  at  Jefferson  Medical  College  and  other  schools  of 
Medicine. 

"One  of  the  most  careful,  ornate,  and  accessible  |  "  We  consider  the  views  of  the  author  on  the  subject 
manuals  on  the  subject." — London  Lancet.  of  therapeutics  as   rational   in  the  highest  degree." — 

I    Boston  Medical a7id  Surgical  yournal. 

MEMORANDA  OF  POISONS. 

A  Memoranda  of  Poisons  and  their  Antidotes  and  Tests.  Fifth  American, 
from  the  Last  London  Edition.     Revised  and  Enlarged.  In  Press. 

This  most  complete  Toxicological  Manual  should  be  within  reach  of  all  physi- 
cians and  pharmacists,  and  as  an  addition  to  every  family  library,  would  be  thc 
means  of  saving  life  arid  allaying  pain  when  the  delay  of  sending  for  a  physician 
would  prove  fatal. 


PUBLICA  TIONS.  39 


TIBBETS,  MEDICAL  ELECTRICITY. 

A  Hand-book  of  Medical  Electricity.  Giving  full  directions  for  its  Applica- 
tion, etc.     By  Herbert  Tibbets,  m.d.     64  Illustrations.     8vo. 

TRANSACTIONS  OF  THE  COLLEGE  OF  PHYSICIANS. 

The  Transactions  of  the  College  of  Physicians  of  Philadelphia.  New  Series. 
Vols.  I,  II,  III,  IV.     8vo.  Price,  per  volume,  I2.50 

Vol.  V.  Containing  Articles  and  Discourses  by  Drs.  Atlee,  DaCosta,  Mills, 
A.  V.  Meigs,  H.  C.  Wood,  Cohen  ;  Profs.  Tyson,  Gross,  Bartholow,  Allen,  Leeds 
and  others.    Just  Ready.  Cloth,  Gilt  Top,  ^3.50 

TYSON,  BRIGHT'S  DISEASE  AND  DIABETES. 

A  Treatise  on  Diabetes  and  Bright's  Disease.  With  Especial  Reference  to 
Pathology  and  Therapeutics.  By  James  Tyson,  m.d..  Professor  of  Pathology 
and  Morbid  Anatomy  in  the  University  of  Pennsylvania.  With  Colored  Plates 
and  many  Wood  Engravings.     8vo.  Price  $3.50 


"  This  volume  is  the  outcome  of  some  fifteen  years' 
special  study  and  observation,  and  will  be  found  to  be 
a  very  well  prepared  monograph His  direc- 
tions are  clear  and  minute. — Med.  and  Surg.  Reporter. 


"  The  symptoms  are  clearly  defined,  and  the  treat- 
ment is  exceedingly  well  described,  so  that  every  one 
reading  the  book  must  be  profited  " — Cinchinati  Lan- 
cet and  Clinic. 


BY   SAME   AUTHOR. 

GUIDE  TO  THE  EXAMINATION  OF   URINE. 

A  Practical  Guide  to  the  Examination  of  Urine.  For  the  use  of  Physicians  and 

Students.    With  Colored  Plates  and  Numerous  Illustrations  Engraved  on  Wood. 

Fourth  Edition.     i2mo.  Price  $1.50 

Advantage  has  been  taken,  in  bringing  out  a  new  edition  of  this  work,  not  only  to 

correct  the  previous  one,  but  to  make  such  additions  of  new  Facts  and  Processes  as 

would  add  to  its  value  without  materially  increasing  its  size. 

"Dr.  Tyson  commences  with  a  short  account  of  the  theory  of  renal  secretion,  the  physical  and  chemical  charac- 
ters of  the  urine,  and  the  reagents  and  apparatus  used  in  its  analysis.  Excellent  rules  are  then  given  for  detecting 
the  presence  of  albumen,  sugar,  coloring-matters,  bile,  urea,  uric  acid,  chlorides,  phosphates  and  sulphates  ;  and 
minute  instnictions  for  approximative  and  quantitative  determination  of  most  of  those  ingredients  by  volumetric 
analysis  are  supplied." — Philadelphia  Medical  Times. 

"  We  have  experienced  both  pleasure  and  profit  ftom  the  perusal  of  this  book.  It  is  agreeably  written,  contains 
much  practical  information,  and  is,  we  believe,  a  rehable  and  satisfactory  guide  to  the  clinical  examination  oJ 
arine.  We  can  recommend  Dr.  Tyson's  book  as  one  that  amply  supplies  the  clinical  needs  of  the  physician." — 
Dublin  yournal  of  Medical  Science. 

THE  CELL  DOCTRINE.     Second  Edition. 

The  Cell  Doctrine.  Its  History  and  Present  State.  With  a  Copious  Biblio- 
graphy of  the  subject.  Illustrated  by  a  Colored  Plate  and  Wood  Cuts.  Second 
Edition.     8vo.  Price  ^2.00 

TURNBULL,  ARTIFICIAL  ANESTHESIA. 

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TEALE,  DANGERS   TO   HEALTH.     Third  Edition. 

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VIRCHOW,  POST-MORTEM  EXAMINATIONS.  Second  Edi- 
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WAGSTAFFE,   HUMAN  OSTEOLOGY. 

The  Student's  Guide  to  Human  Osteology,  By  William  Warwick  Wag- 
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WARNER,  CASE  TAKING. 

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WATERS,  DISEASES  OF  THE  CHEST.     Second  Edition. 

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PUBLICA  TIONS.  41 


WEST,  THE  DISEASES  OF  WOMEN.     Fourth  Edition. 

Lectures  on   the   Diseases   of  Women.     By  Charles  West,  m.d.     Fourth 
London  Edition.     Revised  and  in  part  re-written  by  the  Author.     With  Numer- 
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tholomew's Hospital     8vo.  Price  ^5.00 
Drs.  West  and  Duncan   are,  perhaps,  the  most  celebrated   London  physicians 
giving  attention  to  the  Diseases  of  Women,  and  together  have  made  a  most  com- 
plete work,  either  for  the  physician  or  student. 

WILKS,  PATHOLOGICAL  ANATOMY. 

Lectures  on  Pathological  Anatomy.  By  Samuel  Wilkes,  f.r.s.  Second 
Edition.  Revised  and  Enlarged  by  Walter  Moxon,  m.d.,  f.r.s..  Physician  to 
and  Lecturer  at  Guy's  Hospital,  London.     8vo.  Price  $6.00 

BY   SAME   AUTHOR. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Lectures  on  Diseases  of  the  Nervous  System,  Delivered  at  Guy's  Hospital, 
London.     New  Edition,  with  Additions,  Numerous  Illustrative  Cases,  etc.     8vo. 

Cloth,  $6.00 

"A  book  of  great  value,  embodying  as  It  does  the  results  of  the  experience  and  observation  of  one  of  the  most 
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WRIGHT,  ON  HEADACHES.     Ninth  Thousand. 

Headaches,  their  Causes,  Nature  and  Treatment.  By  Henry  G.  Wright, 
M.D     i2mo.  Price  .50 

WILSON,  ON  DRAJNAGE. 

Drainage  for  Health ;  or,  Easy  Lessons  in  Sanitary  Science,  with  Numerous 
Illustrations.  By  Joseph  Wilson,  m.d.,  Medical  Director  United  States  Navy. 
One  Vol.     Octavo.  Price  $1.00 

"Dr.  Wilson  is  favorably  known  as  one  of  the  lead-    I        "  Easily  understood,  and  briefly  and  concisely  pre- 


sented."— Providence  yournal. 

"  Will  be  found  of  value." — Boston  Transcript. 

"Worthy  of  praise  as  a  popular  statement  of  the 
subject." — Boston  journal  of  Chemistry. 

"  Will  be  sure  to  be  a  harbinger  of  good  in  every  fam- 
ily whose  good  fortune  it  may  be  to  possess  a  copy." — 
Builder  and  Wood  Worker. 


ing  American  writers  on  hygiene  and  public  health. 
The  book  deserves  popularity." — Medical  and  Surgi- 
cal Reporter. 

"Well  written  and  well  illustrated.  Attention  to  its 
teachings  may  save  much  disease  and  perhaps  many 
lives." — Cincinnati  Gazette. 

"Interesting  as  well  as  useful." — Philadelphia  Led- 
ger. 

BY   SAME   AUTHOR. 

NAVAL  HYGIENE. 

Naval  Hygiene,  or.  Human  Health  and  Means  for  Preventing  Disease.  With 
Illustrative  Incidents  derived  from  Naval  Experience.  Illustrated.  Second 
Edition.     Svo.  Price  $3.00 

WILSON,    HOW  TO  LIVE. 

Health  and  Healthy  Homes.  A  Guide  to  Personal  and  Domestic  Hygiene. 
By  George  Wilson,  m.d.,  Medical  Officer  of  Health.  Edited  by  Jos.  G. 
Richardson,  m.d..  Professor  of  Hygiene  at  the  University  of  Pennsylvania. 
314  pages.     i2mo.  Price  $1.00 

Chapter  i. — Introductory,  page  17.  11.  The  Human  Body,  33.  iii.  Causes  of  Disease,  66.  rv.  Food  and 
Diet,  119.  V.  Cleanliness  and  Clothing,  169.  vi.  Exercise,  Recareation  and  Training,  187.  vil.  Home  and  Its 
Surroundings,  Drainage,  Warming,  etc.,  221.     viii.   Infectious  Diseases  and  their  Prevention,  269. 

"  A  most  useful,  and  in  every  way,  acceptable  book." — New  York  Herald. 

"  Marked  throughout  by  a  sound,  scientific  spirit,  and  an  absence  of  all  hasty  generalizations,  sweeping  asser- 
tions, and  abuse  cf  statistics  in  support  of  the  writer's  particular  views.  .  .  .  We  cannot  speak  too  highly  of 
a  work  which  we  have  read  with  entire  satisfaction." — Medical  Titnet  and  Gazette. 

BY    SAME    AUTHOR. 

A  HAND-BOOK  OF  HYGIENE 

And  Sanitary  bcience.  With  Illustrations.  Fourth  Edition.  Revised  and 
Enlarged.     Svo.  Price  $2.75 


42  p.  BLAKISTON,  SON  &^  CO:S 


WILSON,  HUMAN  ANATOMY.     Tenth  Edition. 

The  Anatomist's  Vade-Mecum.  General  and  Special.  By  Prof.  Erasmus  Wil- 
son. Edited  by  George  Buchanan,  Professor  of  Clinical  Surgery  in  the  Uni- 
versity of  Glasgow ;  and  Henry  E.  Clark,  Lecturer  on  Anatomy  at  the  Royal 
Infirmary  School  of  Medicine,  Glasgov/.  Tenth  Edition.  With  450  Engravings 
(including  26  Colored  Plates).     Crown  8vo.  Price  $6.00 

Recommended  as  a  Text-book  at  Rush  Medical  College,  Chicago ;  Bellevue  Hos- 
pital, New  York;  St.  Louis  Medical  College;  Yale  and  Dartmouth  Schools,  and 
many  other  Colleges. 

BY   same   author. 

HEALTHY  SKIN.     Eighth  Edition. 

A  Practical  Treatise  on  the  Skin  and  Hair  ;  their  Preservation  and  Manage- 
ment.    Eighth  Edition.     i2mo.     Paper.  Price  $1.00 

WILSON,  SEA  VOYAGES  FOR  HEALTH. 

The  Ocean  as  a  Health  Resort.  A  Hand-book  of  Practical  Information  as  to 
Sea  Voyages,  for  the  Use  of  Tourists  and  Invalids.  By  Wm.  S.  Wilson,  l.r.c.p. 
Lond.,  m.r.c.s.e.  With  a  Chart  showing  the  Ocean  Routes,  and  Illustrating  the 
Physical  Geography  of  the  Sea.     Crown  8vo.  Price  $2.50 

Chapter  i.  Curative  Effects  of  the  Ocean  Climate.  2.  The  Various  Health  Voyages.  3.  Time  of  Starting — 
Choosing  a  Ship.  4.  PreUminary  Arrangements.  5.  Life  at  Sea.  6.  Climate  and  Weather.  7.  Management  of 
the  Health  at  Sea.  8.  Occupations  and  Amusements  at  Sea.  g.  Objects  of  Interest  at  Sea.  10.  End  nf  the 
Voyage — Future  Plans.  11.  The  Homeward  Voyage.  12.  Australia:  its  Climate,  Cities,  and  Health  ResortB. 
13.  South  Africa  and  its  Climate.     14.  The  Meteorology  of  the  Ocean. 

Appendix  A. — Outfit  Required  for  a  Voyage  to  Australia.  B.  Names  and  Addresses  of  some  of  the  Principal 
Shipping  Firms. 

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Medical  men  may  consult  it  with  advantage,  and  commend  it  to  those  patients  whom  they  may  advise  to  try  the 
effect  of  a  long  voyage  at  se.3.." —Medical  Times  and  Gazette. 

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WELLS,  OVARIAN  AND  UTERINE  TUMORS.     Just  Out. 

The  Diagnosis  and  Surgical  Treatment  of  Ovarian  and  Uterine  Tumors.  By 
T.  Spencer  Wells,  m.d.     Illustrated.     8vo.  Price,  Cloth,  $7.00 

So  long  a  time  having  elapsed  since  Dr.  Wells  has  collected  the  results  of  his 
large  experience  in  book  form,  the  present  volume  will  be  eagerly  looked  for  by  all 
interested  in  this  very  important  subject. 

WOLFE,  ON  DISEASES  OF  THE  EYE. 

A  Practical  Treatise  on  Diseases  and  Injuries  of  the  Eye.  Being  a  Course  of 
Systematic  and  Clinical  Lectures  to  Students  and  Medical  Practitioners.  By  M. 
Wolfe,  f.r.c.p.e..  Senior  Surgeon  to  the  Glasgow  Ophthalmic  Institution,  etc. 
With  10  Colored  Plates,  and  numerous  other  Illustrations.  Octavo.       Price  ^7.00 

WALKER,  INTERMARRIAGE. 

Intermarriage,  or,  The  Mode  in  which,  and  the  Causes  why.  Beauty,  Health 
and  Intellect  result  from  certain  Unions ;  and  Deformity,  Disease  and  Insanity 
from  others.     Illustrated.     i2mo.  Price  $1.00 

WARD'S  COMPEND  OF  CHEMISTRY. 

A  Compend  of  Chemistry  for  Chemical  and  Medical  Students.  By  G.  Mason 
Ward,  m.d..  Demonstrator  of  Chemistry  in  Jefferson  Medical  College,  Phila- 
delphia. Containing  a  Table  of  Elements  and  Tables  for  the  Detection  of 
Metals  in  Solutions  of  Mixed  Substances,  etc.     i2mo.     Cloth. 

Interleaved  for  the  addition  of  Notes,  I1.25  ;  plain,  $1.00 


PUBLICA  TIONS.  43 


WOODMAN  and  TIDY,  MEDICAL  JURISPRUDENCE. 

Forensic  Medicine  and  Toxicology.  By  W.  Bathurst  Woodman,  m.d., 
Physician  to  the  London  Hospital,  and  Charles  Meymott  Tidy,  f.c.s.,  Pro- 
fessor of  Chemistry  and  Medical  Jurisprudence  at  the  London  Hospital.  With 
Chromo-Lithographic  Plates,  representing  the  Appearance  of  the  Stomach  in 
Poisoning  by  Arsenic,  Corrosive  Sublimate,  Nitric  Acid,  Oxalic  Acid ;  the  Spectra 
of  Blood  and  the  Microscopic  Appearance  of  Human  and  other  Hairs ;  and 
1 16  other  Illustrations.     Large  octavo.     Sold  only  by  Subscription. 

Price,  Cloth,  #7.50;  Medical  Sheep,  $8.50;  Law  Leather,  $8.50 

"  Wc  have  no  hesitation  in  pronouncing  the  work  to  be  one  of  unusual  merit.  More  readable  than  Taylor, 
more  systematic  in  its  arrangement,  and  more  practical  in  its  instruction,  it  will  prove  to  the  medical  jurist,  not 
less  than  to  the  general  practitioner,  a  storehouse  of  useful  knowledge,  conveyed  in  an  unusually  graphic  style." — 
Dtiblin  yournal  of  Medical  Science. 

"  The  authors  of  this  truly  great  work  have  largely  supplied  the  want  felt,  sooner  or  later,  by  almost  every 
doctor." — Cincinnati  Lancet  and  Observer. 

"  All  the  best  known  works  on  Medical  Jurisprudence  have  been  laid  under  contribution  for  the  production  of 
the  present  volume.  It  contains  almost  everything  that  can  be  found  in  other  works  on  the  subject ;  but  it  is  no 
mere  compilation.  Dr.  Woodman  and  Dr.  Tidy  have  both  thought  out  the  subject  for  themselves,  and,  with  rare 
industry  and  acumen,  have  brought  together  a  mass  of  facts  which  is  little  short  of  astounding.  The  book  is 
worthy  to  take  its  place  alongside  of  any  work  on  the  same  subject,  and  must  prove  of  great  use  to  all  who  prac- 
tice in  criminal  courts,  and  to  all  medical  practitioners.  We  have  no  hesitation  in  recommending  it  to  our  read- 
ers."— London  Lancet. 

"Altogether  the  work  will  rank  with  the  best  of  its  class  as  a  medico-legal  hand-book,  and  cannot  fail  to  gain 
a  wide  popularity." — Neiv  York  Medical  Record. 

"  It  cannot  be  otherwise  than  a  valuable  contribution  to  the  boundless  subject  of  medical  jurisprudence." — 
Albany  Law  Journal. 

"The  scope  of  this  book  is  very  wide,  and  its  execution  worthy  of  all  commendation." — Philadelphia  Legal 
Intelligencer. 

WYTHE,  ON  THE  MICROSCOPE. 

The  Microscopist.  A  Manual  of  Microscopy  and  Compendium  of  the  Micro- 
scopic Sciences,  Micro-Mineralogy,  Micro-Chemistry,  Biology,  Histology,  and 
Practical  Medicine.  By  Joseph  H.  Wythe,  a.m.,  m.d.  Fourth  Edition.  252 
Illustrations.     8vo.  Price,  Cloth,  ^3.00;  Leather,  I4.00 

An  Index  and  Glossary  have  been  combined  in  this  edition,  so  as  to  be  a  source 
of  valuable  information.  Notices  of  recent  additions  to  the  microscope,  together 
with  the  genera  of  microscopic  plants,  have  been  given  in  an  Appendix. 

"  From  what  we  knew  of  the  author  of  this  work,  as  i  "  This  is  one  of  the  most  valuable  text-books  on  mi- 
a  skilled  practical  Microscopist,  a  successful  teacher  of   j    croscopy  ever  offered  to  students  or  practitioners   of 


the  science,  and  a  practitioner  of  medicine  and  surgery 
of  long  and  varied  experience,  we  had  a  right  to  expect 
a  good  book  from  his  hands.  Our  expectations  are  fully 
realized  in  the  volume  before  us.  The  style  is  clear 
and  distinct,  and  one  reads  the  book  with  the  utmost 
facility  of  comprehension.  It  is  the  more  valuable  to 
the  physician  and  medical  student  on  account  of  its 
closer  application  of  the  microscope  to  medical  subjects 
than  we  find  elsewhere.  The  numerous  plates,  many 
of  which  are  beautifully  colored,  are  not  to  be  excelled. 
We  feel  proud  of  it  as  an  American  production." — 
Pacific  Medical  and  Surgical  Journal. 


medicine.  This  edition  has  been  greatly  enhanced  in 
value  by  the  addition  of  chapters  on  the  use  of  the 
microscope  in  pathology,  diagnosis,  and  etiology,  and 
numerous  new  illustrations,  some  of  which  are  from 
Rindfleisch. 

"  The  author  very  carefully  brings  out  every  neces- 
sary fact  and  principle  relating  to  the  use  of  the  micro- 
scope, and  now  that  this  instrument  has  become  an  es- 
sential part  of  every  practitioner's  armamentarium,  a 
practical  guide  and  reference  book  is  also  a  necessity, 
and  we  are  fully  warranted  in  reiterating  the  statement 
that  this  is  one  of  the  most  valuable  text-books  ever 
offered  to  students  and  practitioners  of  medicine." — 
The  Cincinnati  Lancet  and  Clinic. 


BY   SAME   AUTHOR. 

DOSE  AND  SYMPTOM  BOOK.     Eleventh  Edition. 

The  Physician's  Pocket  Dose  and  Symptom  Book.  Containing  the  Doses  and 
Uses  of  all  the  Principal  Articles  of  the  Materia  Medica,  and  Original  Prepara- 
tions.    Eleventh  Revised  Edition. 

Price,  Cloth,  $1.00;  Leather,  with  Tucks  and  Pocket,  $1.25 

"  The  chapter  on  Dietetic  Preparations  will  be  found  useful  to  all  practicing  physicians,  most  of  whom  have  but 
little  acquaintance  with  the  mode  of  preparing  the  various  articles  of  diet  for  the  sick." — Boston  Medical  and 
Surgical  Journal. 

"  Many  a  hard-worked  practitioner  will  find  it  a  useful  little  work  to  have  on  his  study  table." — Canada  Medical 
and  Su> gical  Journal. 


44  P.  BLAKISTON,  SON  &-  CO:S  PUBLICATIONS. 

WHEELER,  MEDICAL  CHEMISTRY. 

Medical  Chemistry,  Including  the  Outlines  of  Organic  and  Physiological 
Chemistry.     By  C.  Gilbert  Wheeler,  m.d.     Second  Edition.     i2mo. 

Price  $3.00 
WOAKES,  ON  DEAFNESS  AND  GIDDINESS. 

On  Deafness,  Giddiness  and  Noises  in  the  Head;  or.  The  Naso-Pharj-ngeai 
Aspect  of  Ear  Disease.  By  Edward  Woakes,  m.d  ,  Senior  Aural  Surgeon  to 
the  Hospital  for  Diseases  of  the  Throat  and  Chest.  Third  Edition.  Revised  and 
Enlarged,  with  Additional  Illustrations.     i2mo. 

"  Xo  brief  summary  of  his  views  could  do  full  justice  to  the  cogency  and  subtlety  of  his  reasons.  We  prefer 
to  commend  the  whole  work  to  the  thoughtful  perusal  of  all  intelligent  medical  practitioners  who  desire  to  rise 
above  the  level  of  mere  routine  empiricism." — Lancet. 

BY   THE   SAME   AUTHOR. 

WOAKES,  ON    NASAL  CATARRH. 

Post-nasal  Catarrh.     Its  Causes,  Consequences  and  Treatment.  In  Press. 


ILLUSTRATED    BOOKS. 

MEDICINAL  PLANTS. 

Being  Descriptions,  with  original  Figures,  of  the  Principal  Plants  employed  in 
Medicine,  and  an  account  of  their  Properties  and  Uses.  By  Robert  Bentley, 
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NOAA^  READY. 

Diseases  of  the  Liver. 

BY  GEORGE  HARLEY,  M.D.,  F.R.S.,  Etc, 

Author  of  "  The  Urine  and  Its  Derangements,"  and  "  Diabetes,  Its  Various  Forms  and  Tieatment." 

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before  the  profession.     The  reputation  of  its  distinguished  author  is  a  guar- 
antee of  its  merits. 

THE  AUTHOR,  IN  HIS  PREFACE,  SA^b: 

THIS  NE  W  TREA  TISE,  which  I  have  thought  fit  to  entitle  Diseases  of  the  Liver,  with 
and  without  Jaundice,  with  special  apphcation  to  Diagnosis  and  Treatment, 
embodies  within  it  the  whole  substance  of  my  original  monograph  on  Jaundice  and 
Diseases  of  the  Liver ;  though  greater  than  it,  both  as  regards  its  scope  and 
materials,  and  the  large  amount  of  clinical  and  scientific  data  that  has  nevei 
before  been  collected  together  into  one  volume;  while  in  a  great  many  instances 
it  gives  a  new  rendering  to  old  clinical  facts,  by  presenting  them  to  the  reader  in 
the  light  of  modern  pathological  science. 

As  I  think  time  is  quite  of  as  much  value  to  the  professional  as  it  is  to  the  mercantile  man, 
I  have  endeavored  to  condense  my  materials  to  the  utmost,  without  running  the 
risk  of  endangering  their  perspicuity.  Added  to  which,  as  this  treatise  has  not 
been  penned  either  for  the  use  of  the  tyro  or  the  dilettante  in  medicine,  but  for 
that  of  my  qualified  brethren,  I  shall  neither  waste  time  by  entering  into  detailed 
accounts  of  the  literature,  nor  give  tedious,  and  probably  at  the  same  time  profit- 
less, discussions  of  the  theories  of  the  mechanism  of  jaundice  in  hepatic  derange- 
ments. Taking  care,  however,  in  order  that  it  may  carrj'-  more  weight  with  it 
in  the  eyes  of  the  reader,  to  illustrate  it  freely  with  cases  reported  by  indepen- 
dent observers,  both  at  home  and  abroad.  While,  in  order,  again,  that  the  reader 
may  be  able  to  see  for  himself,  at  a  glance,  how  many  of  the  old-fashioned  theories 
of  the  patholog\'  of  jaundice  have  been  abandoned,  as  well  as  how  many  new  ones 
have  been  espoused,  I  have  put  my  views,  in  accordance  with  the  facts  and 
arguments  expressed  throughout  the  body  of  the  volume,  into  a  concise  and 
diagrammatic  tabular  form.  '■ 

[  WOULD  DIRECT  th.&  special  attention  of  my  readers  to  the  chapter  devoted  to 
treatment,  as  well  as  that  at  the  end  of  the  book,  entitled  Hints  on  Diagnosis. 

SYNOPSIS    OF  THE    CONTENTS. 


Introduction,  giving  a  general  view  of  the  scope  of  the 
volume,  and  the  application  of  Physiological  Chemistry 
to  the  diagnosis  and  treatment  of  Hepatic  affections. 

Chemistry,  Physics  and  Physiology  of  the  Liver  and 
its  secretions. 

Etiologj'  of  Jaundice — different  kinds — causes  pro- 
ducing th  -m — treatment. 

Si^as  and  Symptoms  of  Liver  Diseases. 
"^General  remarks  on  all  kinds  of  Hepatic  Remedies. 

Special  Hepatic  Medicines ;  their  modes  of  action 
and  uses. 

Mineral  Waters,  Wines  and  Foods;  treatment  of 
Pyrexia,  Cerebral  complications,  etc. 

Congenital  and  Hereditary  Liver  Diseases,  Bilious- 
ness ;  Its  Varieties  and  Treatment. 

Jaundice  from  Enervation,  all  its  forms  explained  and 
their  different  Treatments 

Different  forms  of  Inflammation  of  the  Liver  and  their 
Treatments. 

Jaundice  caused  by  Disease  Germs,  Yellow  Fevers, 
Contagious  and  Eoidemic  Jaundice,  different  kinds  and 
•iieir  Treatments.  '  Diagnosis. 

Jaundice  of  Pregnancy.  Index. 

Different  forms  of  Hepatic  Atrophy  and  Ascites.  | 


Biliary  Concretions,  Inspissated  Bile,  Gall-Stones  o/ 
every  kind  and  form,  direct  and  indirect  effects  of, 
their  Symptoms  and  Treatment,  \CTy  fully  gone  into. 

Different  kinds  of  Colics,  etc. 

Catarrhal  Jaundice. 

Jaundice  from  Poisons. 

Different  kinds  of  Jaundice  from  Permanent  Obstrnc- 
tions. 

Physiological  Chemistry  of  the  Excretions,  Urine 
and  Stools,  as  a  Guide  to  Diagnosis  and  Treatment. 

All  kinds  of  Abscess,  Tropical,  Pyasmic,  iMetastatic, 
etc. 

Different  kinds  of  Cancers  of  the  Liver  and  its  Appen- 
dages. 

Hydatid  and  Cystic  Diseases  of  the  Liver  ;  Syphilitic 
and  Fibroid  Diseases  of  the  Liver. 

Embolisms,  Fatty,  Amyloid  and  other  Degenerations 
of  the  Liver. 

Traumatic  Diseases  of  the  Liver. 

Diseases  of  the  Gall  Bladder. 

A  concluding   chapter,  entitled  Hints  on  Differential 


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PRESS  NOTICES  AND  RECOMMENDATIONS 

OF 

Dr.  George  Harley's  New  Book  on 

Diseases  of  the  Liver. 


"  The  Medical  Profession,  botl '  n  Englani  and  Amer- 
ica, has  for  some  time  been  on  '^^.-i  qui  vive  v^x  this  new 
work  on  the  Liver,  both  because  hepatic  literature  is  mea- 
gre in  the  extreme,  and  because  it  was  well  known  that 
Prof.  Harley  was  specially  qualified  to  write  an  authorita- 
tive work  on  the  subject.  .  .  .  The  author  has  unques- 
tionably written  the  most  valuable  work  on  hepatic  dis- 
eases that  has  yet  appeared.  We  must  confess  that  we 
have  tried,  and  tried  hard,  to  find  some  error  in  the  work, 
to  preclude  the  charge  of  partiality  being  made." — Vir- 
ginia Medical  Monthly. 

"  It  is  one  of  the  freshest,  most  readable,  and  most 

instructive  medical  books  that  have  been  laid  upon  our 

table  during  the  present  decade.    ...  In  conclusion,  we 

commend  again  most  heartily   Dr.    Harley's  extremely 

"  valuable  book." — Philadelphia  Medical  Times. 

"The  work  is  far  in  advance,  in  original  and  practical 
information,  of  any  treatise  on  the  subject  with  which  we 
are  acquainted,  and  is  worth  man)-  times  its  cost  to  any 
physician  treating  hepatic  troubles." — Chicago  Medical 
Tivtes. 

"  The  whole  subject-matter  is  treated  in  a  masterly 
manner,  and  the  work  is  destined  to  find  a  place  among 
the  classics." — Medical  Herald,  Louisville ,  Ky. 

"  It  is  the  outcome  of  a  mind  that  went  to  its  task 
amply  equipped  therefor.  It  is  the  product  of  long  think- 
ing and  ripe  judgment.  .  .  .  We  must  content  ourselves 
with  this  bare  statement  hoping  that  those  who  read  the 
book  will  derive  as  much  benefit  as  ourselves." — NeUi 
Orleans  Medical  and  Surgical  yournal. 

"  The  work  before  us  is  one  of  the  most  thoroughly 
scientific  ever  offered  to  the  medical  profession  upon  the 
diagnosis  and  treatment  of  diseases  of  the  liver.  This 
book  will  prove  especially  valuable  to  the  Southern  prac- 
titioner, who,  on  account  of  climatic  influences,  is  daily 
forced  to  combat  these  ailments.  In  this  section  of 
country  hepatic  disorders  are  not  only  common  as  inde- 
pendent conditions — diseases  per  se — but  they  form  im- 
portant factors  in  the  production  of,  and  are  ordinary 
concomitants  of,  most  of  our  malarial  diseases." — The 
Missi*-*ippi  Valley  Medical  Monthly,  Memphis,  Tenn. 

"  The  work  of  Dr.  Harley  is  the  most  complete  work 
upon  diseases  of  the  liver  now  before  the  profession.  It 
embodies  not  only  the  results  of  his  own  large  experience 
and  observations,  but  also  exhibits  the  researches  of  oth- 
ers in  the  same  class  of  diseases.  As  a  scientific  treatise 
of  hepatic  affections  and  their  treatment,  it  will  certainly 
hold  a  first  position  among  the  standard  works." — Cin- 
cinnati Medical  N'ezus. 

"  We  regard  it  as  one  of  the  most  valuable  of  the  recent 
additions  to  medical  literature." — Southern  Practitioner, 
Nashville,  Tenn. 


"  His  especial  point,  as  mdicated  in  the  titie,  is  to 
bring  prominently  forward  the  relations  of  physiology  to 
the  forms  of  disease.  Too  exclusive  attention,  he  thinks, 
has  been  paid  to  pathology.  It  has  been  regr.rded  as  a 
science  apart.  The  great  truth  has  been  overlooked  that 
the  same  fundamental  laws  regulate  the  phenomena  both 
of  health  and  disease. 

"  With  this  as  his  guiding  principle,  he  approaches  the 
complicated  problem  of  '  liver  complaints'  and  '  bilious 
ness'  with  a  much  stronger  hand  than  his  predecessors  in 
that  field.  Aflflicted  as  many  districts  of  our  country  are. 
with  many  and  puzzling  forms  of  these  maladies,  we  be- 
lieve Dr.  Harley's  volume  will  be  a  welcome  addition  to 
many  a  library." — Philadelphia  Meidcal  and  Surgical 
Reporter. 

"  We  have  read  the  volume  before  us  with  peculiar  in- 
terest, and  it  will  be  read  especially  by  Southern  doctors, 
who,  although  they  do  not  have  a  monopoly  of  diseases 
of  the  liver,  by  reason  of  semi-tropical  malarial  climate 
encounter  a  large  proportion  of  such  diseases.  .  .  .  We 
most  heartily  commend  this  book  to  our  readers  as  a  val- 
uable addition  to  the  working  volumes  of  their  libraries  ; 
for  without  any  exception  it  is  the  most  entertaining  and 
instructive  volume  we  had  the  pleasure  of  reading  for 
many  years." — North  Carolina  Medical  Journal. 

"  The  author  has  succeeded  admirably  in  the  work  he 
has  undertaken,  and  has  placed  before  the  profession  a 
work  that  will  be  of  inestimable  value  to  the  practi- 
tioner."— Nashville  Journal  of  Medicine  and  Surgery. 

"  His  chapter  on  '  Hints  to  Aid  in  the  Diagnosis  of 
Liver  Disease,'  is  one  of  the  best  in  the  book,  and  will 
amply  repay  any  one  for  its  perusal." — Indiana  Medical 
Journal. 

"  With  unusual  gratification  we  have  received  this 
most  excellent  work,  and  present  it  to  the  niedical  profes- 
sion with  an  unqu.alified  endorsement.  We  know  of  no 
work  of  the  kind,  as  this,  based  upon  the  unvarying  rela- 
tion between  physiology  and  pathology,  the  only  avenue 
of  approach  to  the  cause  of  disease  and  proper  treat- 
ment."— Missouri  Valley  Medical  Journal. 

"  Those  features  which  are  the  most  noteworthy  from 
their  novelty,  or  as  showing  individuality  in  treatment,* 
are  to  be  found  in  the  chapter  on  '  The  General  Treat- 
ment of  Hepatic  Disease,'  and  in  that  on  the  '  Chemistry 
of  the  Excretions.'  In  the  former  the  author  takes  up 
the  most  prominent  articles  in  the  materia  medica  having 
a  reputation  in  this  class  of  diseases,  and  considers  their 
chemistry,  their  mode  of  action,  and  the  conditions  which 
seem  to  indicate  their  employment,  after  adding  brief 
cases  in  illustration." — New  York  Herald. 

"  We  commend  the  book  to  the  profession  as  eminently 
worthy  of  study,  and  one  that  should  be  in  the  library  of 
evry  physician." — Southern  Medical  Record. 


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4^  SENT,  POSTPAID,  ON  RECEIPT  OF  PRICE. 

BEALE  ON  SLIGHT  AILMENTS. 

SLIGHT  AILMENTS:  Their  Nature,  Causes,  and  Treatment.  By  Lionel  S.  Beale,  m.d., 
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its  Treatment.     Diarrhoea.     Vertigo.     Giddiness.    Biliousness.     Sick  Headache.     Neuralgia. 

•  Rheumatism.     The  Feverish  and  Inflammatory  State.     Of  the  Actual  Changes  in  Fever  and 

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TILT  ON  CHANGE  OF  LIFE  IN  WOMEN. 

THE  CHANGE  OF  LIFE  IN  WOMEN,  IN  HEALTH  AND  DISEASE.  A  Clinical 
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LACERATIONS  OF  THE  FEMALE  PERINEUM  AND  VESICO- VAGINAL 
FISTULA.  Their  History  and  Treatment.  With  75  Illustrations.  By  D.  Hayes  Agnew, 
M.D.,  Professor  of  Surger}',  University  of  Pennsv'lvania.     Octavo.     Ready. 

Price,  in  Strong  Paper  Covers,  75  Cents;  Cloth,  $1.25 

So  many  applications  haring  been  made  for  these  papers,  as  originally  issued,  it  has  been 
thought  best  to  bring  them  before  the  profession  in  the  present  form. 
"  The  literature  of  the  subject,  its  historj',  causes,  complications,  and  various  modes  of  treatment,  -re  given.     The 
various  methods  of  radical  cure  are  classified." — Indiana.  Jourral  of  Medicine. 

"  These  two  monographs  will  merit  this  more  durable  and  convenient  form." — A/n.  journal  0/  Cbstetrtc^. 

DAY  ON  HEADACHES. 

THE  NATURE,  CAUSES  AND  TREATMENT  OF  HEADACHES.  By  W^illiam 
Henry  Day,  m.d.,  author  of  a  "  Treatise  on  the  Diseases  of  Children."  Fourth  Edition, 
with  Illustrations.     Octavo.      Just  Ready. 

Price,  in  Strong  Paper  Covers,  75  Cents;  Cloth,  $1.25. 

Sl-mmajry  of  Contents.— Headache  from  Cerebral  Ansemia,  Cerebral  Hypersemia;  S>Tnpathetic,  Congestive, 
Dyspeptic  or  Bilious  Headaches;  Headache  from  Plethora,  from  E.xhaustion,  from  Change  in  Cerebral  Tissue,  from 
Affections  of  the  Periosteum  ;  Nervous  and  Neri-o-Hypersemic  Headache  ;  Toxemic,  Rheumatic,  Arthiitic  or  Gouty 
Headache;  Neuralgic  headache,  and  Headaches  of  Childhood,  Early  and  Advanced  Life. 

ALLINGHAM  on  DISEASES  of  the  RECTUM. 

FISTULA,  HEMORRHOIDS,  PAINFUL  ULCER,  STRICTURE,  PROLAPSUS, 

.;nd  all  other  Diseases  of  the  Rectum.  Their  Diagnosis  and  Treatment.  By  William 
Allingham,  m.d.  Fourth  Enlarged  and  Improved  Edition,  with  Illustrations.  Octavo. 
Just  ready.  Price,  in  Strong  Paper  Covers,  75  Cents;  Cloth,  $1.25 

*^*  The  publishers  have  also  a  few  copies  of  a  much  finer  edition  of  Dr.  Allingham's  book. 

Printed  in  London,  on  thick  paper,  from  large  tj-pe,  the  illustrations  being  printed  on  separate 

sheets.     Price,  Extra  Cloth,  ^3.00. 

"  No  book  on  this  special  subject  can  at  all  approach  Allingham's  in  precision,  clearness  and  practical  good  sense." 

— London  Medical  Timesfand  Gazette. 

"  It  is,  as  indeed  the  verdict  of  the  profession  has  already  pronounced  it,  one  of  the  very  best  works  on  Diseases  oi 

the  Rectum." — American  yournal  of  Medical  Science. 

j^^No  subscribing  nuisance  is  connected  with  this  series,  each  volume  is  sold  separately,  01 

the  five  -will  be  sent,  postpaid,  upon  receipt  of  35.00,  for  Cloth  Binding,  or  for  S3.00  in  Paper  Covers, 

P.  BLAKISTON,  SON  &  CO..  1012  WALNUT  STREET,  PHILADELPHIA 


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